IV NCLEX

A client is admitted to the hospital with dehydration and pneumonia. Upon admission to the unit, the nurse notes the I.V. has infiltrated. What is the most appropriate action by the nurse? A. Stop the infusion, remove the I.V. catheter, and restart the infusion in another site. B. Remove the I.V. catheter and apply a cool compress to the site. C. Apply moist heat to the site D. Gently massage the site

A. Immediately after discovering an I.V. infiltration, the nurse should stop the infusion, remove the catheter, restart the IV at another site, and apply a warm compress to the infiltrated site. A cool compress doesn't promote fluid absorption. Moist heat shouldn't be applied until the infusion has stopped, the catheter is removed, and another catheter is inserted at a different site. Massaging the site is likely to cause pain and isn't effective in treating an infiltration.

A nurse is checking the insertion site of a peripheral IV catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of: A. Phlebitis of the vein B. Infiltration of the IV line C. Hypersensitivity to the IV solution D. An allergic reaction to the IV catheter material

A. Phlebitis of the vein Infiltration would have a cool, pale, and swollen area. Phlebitis is inflammation of the vein, which has the s/s of redness, warmth, and pain.

A patient with a PICC line attempts to lift heavy weights. What rationale would the nurse give to have him discontinue this activity?

Excessive physical activity can lead to catheter dislodgement and possible lumen occlusion (BV blockage)

A nurse is doing a routine assessment of a client's peripheral IV site. The nurse notes that the site is cool, pale, and swollen. The IV has stopped running. The nurse determines that which of the following has probably occurred? A. Phlebitis B. Infection C. Infiltration D. Thrombosis

C. Infiltration When an IV has infiltrated into the surrounding tissue, all the fluid goes there. The fluid overload causes the area to be cool, pale, and swollen. The IV stops running because there's nowhere else for the fluid to go if all the tissue is soaked up.

A client receiving ciprofloxacin intravenously reports that the peripheral IV insertion site has become painful and reddened. In what order will the nurse perform the needed actions to manage the problem? A. Report the patient's problem to the healthcare provider B. Document findings and actions in the electronic health record C. Change the IV insertion site to a new location D. Stop the infusion of the drug immediately

D, A, C, B

Which assessment finding would lead the nurse to suspect that a patient's IV has infiltrated? A. In the past hour, only 50 mL of fluid has infused B. The insertion site is red, hot, and swollen C. The patient's temp. rose to 101 D. The site is pale, cool, swollen, and painful

D. A is not as significant as D's findings. B and C are incorrect b/c these s/s would indicate phlebitis

A nurse has been instructed to discontinue an IV line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with a(n): A. Band-Aid B. Alcohol swab C. Betadine swab D. Sterile 2x2 gauze

D. Sterile 2x2 gauze

Which of these catheters is intended for long-term use? A. PICC Line B. Midline Catheter C. Nontunneled Central Venous Catheter (CVC) D. Tunneled Central Venous Catheter

D. Tunneled Central Venous Catheter

Total Parenteral Nutrition (TPN) offers high concentrations of dextrose, it can lead to high levels of _______, which require the administration of _________

Glucose, insulin

Why would we not want to insert short peripheral catheters into lower extremities? What could develop?

If inserted into lower extremities, Deep Vein Thrombosis (DVT) and infiltration could occur

Where does a jejunostomy tube feed into?

Intestine

Where are midline catheters inserted?

Midline catheters are inserted via upper arm. The tip resides in a peripheral vein

Where are short peripheral catheters inserted?

Often inserted into superficial veins of the forearm

What are common complications with PICC lines?

Phlebitis - inflammation of the vein DVT

Where does a gastrostomy tube feed into?

Stomach

Where are PICC lines inserted?

Through an inner elbow vein or middle of the upper arm. The tip rests in the superior vena cava - this is closer than midline catheters

What is the difference between warm and cold compresses in regards to treating infiltration?

Warm compresses increase circulation and speed healing. Cold compresses relieve discomfort and reduce swelling.