IV Therapy Final

Which of the following is method of evaluation of an IV drug effect?

(All of the above) -Assessment of pain level after Morphine Injection -Measurement of blood sugars with an insulin drip -Measurement of urine output with a dopamine drip

Highest risk for dehydration:

-2 month old has been vomiting for 48 hours -90 yr old with diarrhea for 3 days

Recommended antiseptic solutions to use before venipunctures are:

-70% Isopropyl Alcohol -Chlorhexidine gluconate -Povidone-iodine

List the two body systems that are primarily involved in fluid and electrolyte balance

-Kidney -Respiratory

Which of the following factors should be considered in selecting IV equipment

-Latex free components -Safety design -Performance

A physician has written a prescription to discontinue an IV line. The nurse obtains which of the following supplies from the unit supply area for applying pressure to the site after removing the IV catheter?

2x2 gauze (follow facility policy)

When the physician writes an ambiguous medication order, the nurse should

Call the physician who wrote the order

decreased IV flow rate with difficulty, or inability to flush the IV catheter

Catheter occlusion

Utilizing valid and reliable nursing research to guide clinical practice (for example: saline instead of heparin used for flushing saline locks) is known as

Evidence Based Practice

Advantages of IV medication include all except

Extravasation is possible

muscle spasm and twitching, tetany, convulsions, positive Chvostek's sign

Hypocalcemia

ECG changes, fatigue, muscle weakness, anorexia

Hypokalemia

Fatigue, headache, apprehension, Na + 115, mental status changes, muscle twitching, tremors

Hyponatremia

Can be caused by a lack of vitamin D with symptoms of confusion, weakness, seizures

Hypophosphatemia

You are admitting a client to the med-surg floor for pneumonia. When obtaining a hx she explains her dyspnea and fever started today, but that she was at a friend's house three days ago and her friend was just getting over a cold. The time period between visiting her friend and the start of her symptoms is called

Incubation

Hypovolemia would generally be treated with which type of IV solution

Isotonic

Solutions

Isotonic: 0.9% NS Hypotonic: 0.45% NS Hypertonic: 3% NaCl

Before a patient is started on fluid replacement therapy the first thing that should be checked is the person's

Kidney function

The hormones ADH, aldosterone, and renin are important to patients health because they

Maintain the fluid balance by encouraging the kidneys to retain or excrete water

When establishing and maintaining IV containers, tubings, and connections, it is important to reduce infection by

Maintaining sterility of the system

Causes of fluid and electrolyte imbalances include

Major illness or disease and injury

Advocating for the best interests of individual patients is included in both the practical and professional nursing scope of practice in the current revisions of the nurse practice act

True

Evidence shows that sterile gauze dressing and sterile technique are comparable in their rates of causing a catheter-associated infection

True

In terms of quality, the standard of care is the expected patient care outcome

True

Sudden pain or cramping at the IV insertion site; slowed infusion rate.

Venous spasm

Which patient is at the greatest risk for developing a bloodstream infection?

An elderly patient who has been in the hospital for two weeks after a colon resection receiving total parenteral nutrition through a subclavian central line

A 50 yr old coherent adult patient who speaks minimal english comes into the ER seeking care. An order is received to start an IV. The nurse tells the patient he/she is going to initiate the IV whether the patient understands or not and start the IV on the patient. In this situation the nurse could be charged with

Assault and Battery

Before giving IV morphine sulfate, the most important nursing assessment would be to

Assess respirations

Nursing process in order

Assessment, Nursing Diagnosis (analysis), Goals (planning), Implementation, Evaluation

humoral immunity, antibody production

B Cells

Inflammatory response, histamine and heparin producing

Basophils

The nurse will use a parallel infusion set when administering

Blood Products

When educating the patient and the caregiver in the home setting regarding infusion therapy, it is important to assess

-The patient and caregiver's competence -The environment the patient lives in to ensure proper storage of the infusion -The ability for the patient and/or caregiver to respond to an emergency

When flushing a central line, which syrine must be used to prevent rupture of the catheter?

10 mL syringe

Tom Jone's is a 40 year old being admitted to the hospital today with pneumonia. He works as a construction worker. His weight is 175 lbs and on initial assessment he has veins that are easily visualized. On admission his CBC showed the following: WBC= 20.2, Hgb=15, Hct=43%, RBC=4.8, and platelet count 175,000. What size gauge needle will be used for IV therapy?

20G

As you administer an IV push medication to your patient, he becomes flushed and complains of dizziness and headache. His blood pressure drops and his heart rate becomes irregular. You should

Conclude that he is experiencing speed shock, stop the medication, call for help

You are the nurse in charge of obtaining a written consent from an alert and orientated patient in which the physician wants to place a central line. The rationale for the procedure has been explained, but the patient still has questions about the risks and benefits of central line placement. What should your reaction be?

Have the physician explain the risks and benefits of the procedure prior to the consent being signed and the start of the procedure.

Ecchymosis over and around insertion area which is raised and hardened at insertion site; inability to advance cannula into the vein. Can result if the tourniquet is not removed before opening the flow rate

Hematoma

In patients with fluid volume excess, the following symptoms may be present

High BP, dilute and increased urine output and peripheral edema

Reapplying tegaderm

Minimize wrinkles

phagocytes, differentiate into macrophages to clean up injured tissue

Monocytes

first responders, phagocytes

Neutrophils

Which of the following factors contribute to medication errors?

Pump programmed incorrectly, mathematical error in converting measurements, inadequate staffing (All of the above can contribute to medication errors)

The insulin preparation that can safely be given IV is

Regular insulin

fever, chills, decreased BP, malaise, tachycardia

Septicemia

The Dr. has ordered a chemotherapy drug for the patient because of lung cancer. The daughter of the patient does not want the patient to know what medication is truly for because she fears the patient will refuse it. This is an example of which type of ethical issue?

Veracity

First step in a routine venipuncture

Verify physician's order

You are preparing to give an IV push dose of Dilantin though the patient's IV infusion. As you push in the medication solution. You conclude that

a physical incompatibility has occurred

Diffusion is a passive process in which molecules move from

an area of high concentration to one of low concentration

Metabolic acidosis

excessive loss of bicarb

Respiratory alkalosis

hyperventilation

The half life of a medication refers to the time

it takes for the body to metabolize and eliminate one half of the original concentration of an administered drug

Should any opioid side effect occurs, the antagonist of choice is IV

naloxone (Narcan)

Respiratory acidosis

resp problems

The initial symptom that will develop with dehydration is

Thirst

slow/stopped infusion edema at the insertion site. Site warm to touch, visible red line and edema along vein

Thrombophlebitis

When using Chlorhexidine as an antiseptic for IV insertion, use a circular motion from the insertion site out about 2-4 inches

FALSE (back and forth motion)

When performing a venipuncture, after the nurse enters the skin the next step is to lower the angle of the cannula. The rationale for this is

To ensure the nurse does not go through the other side of the vein

A nurse may be in violation of criminal law if they violate a state's nurse practice act or violate safe nursing practice

True

RN initiating peripheral IV, she passed through the epidermis and dermis and upon advancing the cannula a little further feels a "pop." Based on what she knows she has entered which part of the vein?

Tunica Adventitia

When excessive anticoagulant effects occur, the antagonist for heparin is

protamine sulfate.

Infant who is 6 months, most accessible for venous access device is

scalp

IV medication may be indicated when

the medication can't be absorbed by the GI tract

Metabolic alkalosis

vomiting, GI suction, and consuming too many antacids

The nurse is completing a time tape for a 1000 ml IV bag that is scheduled to infuse over 8 hours. The nurse has just placed the 11am marking at the 500ml level. The nurse should place the mark for noon at the 350ml level on the time tape.

FALSE.

A written exam is enough to prove competency in IV therapy

False

According to the nation standards, a peripheral catheter is preferred for infusion therapy which will last 10 days or less

False

An unusual occurrence report is part of the client's chart

False

Aseptic technique only apply to central venous access devices, not peripheral access devices

False

Beneficence is an ethical component which indicates the patient has the right to make independent choices

False

Macrodrip tubing is most commonly used for pediatric patient for IV therapy

False

Legal Standards regarding infusion therapy are derived from

Federal statutes, professional standards, institutional standards (all of the above)

Redness at IV site, patient denies pain is the what degree of phlebitis?

First

cell mediated immunity

T Cells

Examples of negligence in regards to infusion therapy include

1) The physician ordered morphine sulfate every 4 hours IV. The nurse did not administer because he did not think the patient was in pain. 2) The ordered rate on an IV is 100ml/hr. A 1000ml bag of saline is initiated via gravity drip. Upon return 2 hours later the nurse notes the patient is SOB and the IV bag only has 200ml remaining.

Ricky Johnson is an 84 yr old who is in the hospital with pneumonia. On admission his CMP reveals a K+ of 3.2 meq/hr. The Dr. Orders for him to have potassium riders of 20 meq. The rate of administration of IV potassium chloride via a peripheral catheter should not exceed

10-20 meq/hr

Secondary tubing needs to be changed every

24 hours

Your patient needs a central line for chemotherapy to be given monthly for 2 days over the next year. He works as a sandblaster and has a 2 yr old son. He lives 90 miles from the oncology clinic. What would you recommend as a central access device for him?

A port because it will be less exposed to infection risk and will require minimal maintenance when not in use

Several barriers which can influence patient education and infusion therapy include: physical problems, culture issues, age, psychosocial needs

All of the above

The nurse caring for a 68 year old man just completed a physical exam and finds that the patient is unsure of where he is. The nurse also notes sunken eyes, his mouth is dry, his tongue has an extra longitudinal furrow and his lips are cracked. The patient's hand vein filling takes longer than 5 seconds, tending it apparent over the sternum, the vital signs are 110/60, HR 92, RR 12. Based on this assessment the nurse would suspect?

Fluid volume deficit

After gathering your IV start supplies, you are about to enter a room of a patient with C-diff. What precautions are needed prior to entering the room and starting a peripheral IV on this patient?

Gown and Gloves

Decreased urine output, lethargy, increased temperature, poor skin turgor

Hypernatremia

Within one to two minutes after receiving a local anesthetic, the patient experiences tightness in chest, progressing to severe bronchospasm and hypotension. Which is least likely to alleviate these symptoms and signs?

IV Fluids

Swelling at IV site, discomfort, burning, decreased (cool) skin temperature, absent blood backflow

Infiltration

The nurse is preparing a new continuous intravenous at the medications cart. As the nurse goes to attach the distal end of the IV tubing to a needleless device, the exposed tubing hits the top of the medication cart. Which of the following is the appropriate action by the nurse?

Obtain new IV tubing

A nurse may attempt peripheral venipuncture using the same cannula

Only once

patient's subjective description (ache, burn, hurt, stinging) of discomfort

Pain

The best way to prevent needlestick exposure is: through the use of needleless system in all agencies, through the use of care and precaution in handling needles and disposing of needles in approved sharps containers, by not recapping used needles.

All of the above

The nurse's role in IB therapy includes: Professional accountability and skill, safety and efficiency in delivering IV medications and fluids, protecting the client from potential associated with IV therapy

All of the above

You patient is receiving Vancomycin IVPB to treat a methicillin resistant infection. A peak and trough level are ordered. Vancomycin requires this monitoring because

(All the above) -It has a very narrow therapeutic index -The effective dose is very close to the toxic dose -The adverse response to a high blood level is very serious

Which of the following components which can be included in IV solutions?

(All the above) -Water -Amino acids -Dextrose -Trace Elements

Which of the following are first line defense mechanisms? Select all that apply

-Tears -Skin -Intestinal peristalsis

mediates allergic reactions

Eosinophils

When a patient is receiving IV therapy, both the patient and the IV site should be monitored how often?

Every hour or more frequently if the condition warrants it

You assess your patient and find the following signs and symptoms: fatigued muscles, complaints of nausea and anorexia, irritability, diminished deep tendon reflexes and a prominent U wave on the EKG. You check electrolytes and fine: Chloride 92 meq/L, potassium 3.1 meq/L, sodium 135 meq/L, and calcium 10.8 mg/dL. What would you expect the treatment to be?

Replacement therapy with potassium chloride

A client had a 1000ml bag of 5% dextrose in 0.9% sodium chloride hung at 3am and the ordered rate was 100ml/hr. The nurse making rounds at 3:45am finds that the client is complaining of a pounding headache and is dyspneic, is experiencing chills, and is apprehensive, with an increased pulse rate. The intravenous bag has 400ml remaining. The nurse should take which action first?

Slow the IV infusion

When administering a vesicant agent, the nurse suspects infiltration. The highest priority nursing action is to

Stop the infusion of medication

The nurse notes that the patient has no known allergies and administers the first dose of an IV antibiotic. During the next dose, the nurse observes the patient has a fine red rash and rhinitis . Which intervention has the highest priority?

Stop the medication and report the reaction to the MD

One the skin is punctured, the immune system starts a reaction. The line of defense in relation to the immune system is

The release of neutrophils

An alcohol based hand rub is prefered for hand hygiene, except when exposure to spore forming pathogens like C-Diff is expected, then soap and water should be used to wash hands

True