IV Therapy
Which intravenous (IV) fluid should the nurse prepare when a patient requires an isotonic solution? A. 0.9% Normal saline B. 2.5% Dextrose in water C. 0.33% Sodium chloride D. 5% Dextrose in lactated Ringer's
A A. An example of an isotonic solution is 0.9% normal saline. B. An example of a hypotonic solution is 2.5% dextrose in water. C. An example of a hypotonic solution is 0.33% sodium chloride. D. An example of a hypertonic solution is 5% dextrose in lactated Ringer's solution.
The nurse is assessing an intravenous (IV) insertion site noting redness, warmth, and mild swelling. The patient reports a burning pain along the course of the vein during medication administration. Which term should the nurse use when documenting these findings in the medical record? A. Phlebitis B. Infiltration C. Extravasation D. Occlusion
A A. Redness, warmth, edema, and pain that runs along the course of the vein characterize phlebitis. B. An infiltrate is defined as fluid entering the tissues, resulting in swelling, coolness, pallor, and discomfort at the site. C. Extravasation includes a vesicant drug (one that causes blistering when in the tissues but not in the vascular system), so this is not an extravasation. D. An occlusion develops when the there is no flow through the IV catheter, and the site is not warm and red.
The nurse should intervene if a patient receiving a blood transfusion develops the following clinical manifestations of circulatory overload. Select all that apply. A. Dyspnea B. Decreased urine output C. Bradycardia D. Increased blood pressure E. Jugular venous distention
A, D, E A. This is correct. Clinical manifestations of circulatory overload include dyspnea, headache, jugular vein distention, edema, and increased blood pressure. B. This is incorrect. Urine output would most likely increase with circulatory overload. C. This is incorrect. The heart rate may remain at baseline or increase with circulatory overload. D. This is correct. Clinical manifestations of circulatory overload include dyspnea, headache, jugular vein distention, edema, and increased blood pressure. E. This is correct. Clinical manifestations of circulatory overload include dyspnea, headache, jugular vein distention, edema, and increased blood pressure.
In providing care to a patient with a severe fluid deficit, which prescribed intravenous solution does the nurse recognize as most effective in expanding plasma volume? A. 0.9 % Normal saline B. Dextrose 10% C. 0.45 % Normal saline D. Albumin
D A. 0.9% Normal saline is an isotonic fluid and is a crystalloid solution. B. Dextrose 10% is a hypertonic crystalloid solution and would not be used as a plasma volume expander. C. 0.45% Normal saline is a hypotonic crystalloid and promotes fluid moving out of the intravascular space leading to depletion of intravascular fluid volume. D. Colloidal solutions are often referred to as plasma volume expanders because the larger molecules do not diffuse through cell membranes and draw fluid into the intravascular space. Colloidal solutions are used to maintain intravascular volume and prevent shock after major blood or fluid losses. Examples of colloidal solutions include albumin, dextran, and mannitol.
Which intravenous (IV) fluid should the nurse prepare when a patient requires a hypertonic solution? A. 0.9% Normal saline B. 2.5% Dextrose in water C. 0.33% Sodium chloride D. 5% Dextrose in lactated Ringer's
D A. An example of an isotonic solution is 0.9% normal saline. B. An example of a hypotonic solution is 2.5% dextrose in water. C. An example of a hypotonic solution is 0.33% sodium chloride. D. An example of a hypertonic solution is 5% dextrose in lactated Ringer's solution.
The nurse performs an hourly check of a patient's intravenous site and notes erythema. The patient denies pain or discomfort. Based on this data, what should the nurse document in the patient's medical record? A. Grade 1 phlebitis B. Grade 2 phlebitis C. Grade 3 phlebitis D. Grade 4 phlebitis
A A. Grade 1 phlebitis is documented when erythema is noted at the access site with or without pain. B. Pain at the access site with erythema and/or edema is documented as grade 2 phlebitis. C. Pain at the access site with erythema, streak formation, and/or palpable cord is documented as grade 3 phlebitis. D. Pain at the access site with erythema, streak formation, palpable venous cord greater than 1 in. in length, and/or purulent drainage is documented as grade 4 phlebitis.
Which component should the nurse anticipate will be prescribed for a patient with severe thrombocytopenia? A. Platelets B. Albumin C. Fresh frozen plasma D. Packed red blood cells
A A. Platelets are administered for patients who are bleeding as a result of thrombocytopenia or platelet abnormalities. B. Albumin is administered for volume expansion when crystalloid solutions are not adequate. C. Fresh frozen plasma is anticipated for a patient with a deficiency of plasma coagulation factors. D. Packed red blood cells are anticipated for a patient with acute or chronic blood loss and for patients diagnosed with anemia.
The nurse is providing care to a patient who is receiving a blood transfusion. Ten minutes after the infusion is initiated, the patient reports a headache. On further assessment the nurse notes that the patient is experiencing dyspnea and feels warm to the touch. Which is the priority nursing action by the nurse? A. Stopping the transfusion B. Preparing for a full resuscitation C. Notifying the healthcare provider D. Decreasing the rate of the transfusion
A A. The priority nursing action is to stop the transfusion. If the patient is experiencing a transfusion reaction, this will limit the amount of blood administered. B. There is no need for resuscitation based on the current data. C. Although the nurse would contact the healthcare provider, this is not the priority. D. Slowing the rate of the transfusion allows for the blood to continue to be administered; therefore, this is not an appropriate nursing action.
The nurse is providing care to a trauma patient who will require the rapid administration of large volumes of fluid in addition to a blood transfusion. Which gauge should the nurse use when initiating intravenous (IV) access for this patient? A. 18 B. 20 C. 22 D. 24
A A. An 18-gauge catheter is appropriate to initiate IV access for a patient who requires both rapid administration of large volumes of fluid and a blood transfusion. B. A 20-gauge catheter is appropriate for blood transfusion but is not best for the rapid administration of large volumes. C. A 22-gauge catheter is too small for blood and rapid fluid administration. D. A 24-gauge catheter is too small for blood and rapid fluid administration.
The nurse is performing venipuncture to initiate intravenous (IV) therapy. Which indicators should the nurse use when choosing the site for IV therapy? Select all that apply. A. Choosing a straight vein B. Avoiding a sclerotic vein C. Using sites distal to joints D. Using the dominant arm whenever possible E. Avoiding areas of the vein with a valve
A, B, C, & E A. This is correct. Straight veins provide space for the catheter to be inserted easily. B. This is correct. Sclerotic veins make it difficult to obtain and maintain IV therapy. C. This is correct. The site should be sufficiently distal to the wrist or elbow joint to avoid bending or kinking of the IV catheter. D. This is incorrect. It is best, when possible, to use the patient's nondominant arm because movement might be somewhat limited, so the patient should be allowed to use the dominant arm. E. This is correct. Areas of the vein containing a valve should be avoided because the valve acts as an obstruction for the needle to go through the vein.
The nurse is caring for a patient with a central venous catheter (CVC). Which nursing actions should the nurse implement to prevent an air embolism? Select all that apply. A. Using Luer-Lok connections B. Frequently checking connections C. Wearing sterile gloves when accessing any connections D. Clamping catheters and injection sites when not in use E. Placing the patient in low-Fowler position to remove the CVC
A, B, D A. This is correct. The nurse should use Luer-Lok connections to prevent an air embolism. B. This is correct. The nurse should frequently check all connections to prevent air from entering the IV line. C. This is incorrect. Wearing sterile gloves when accessing any connections will not prevent an air embolism. D. This is correct. Clamping catheters and injection sites when not in use will help to prevent an air embolism. E. This is incorrect. The patient should be placed in the supine position for removal of the CVC.
Which patients may benefit from central intravenous (IV) access? Select all that apply. A. The patient receiving caustic IV therapy. B. The patient requiring long-term IV therapy. C. The patient who is afraid of needles and does not want a catheter in the peripheral extremity. D. The patient requiring numerous IV infusions that are not compatible and cannot be infused together. E. The unstable patient requiring reliable IV access for administration of medications required immediately.
A, B, D, E A. This is correct. Central venous access can be very useful for patients requiring long-term IV therapy because the catheter can remain in place for extended periods and IV sites do not have to be changed every few days. B. This is correct. Caustic medications are less likely to cause phlebitis when administered into the large central veins as opposed to the smaller peripheral veins. C. This is incorrect. Because of the potential complications from central venous access, it would not be an option considered because of patient preference if short-term IV therapy is required. D. This is correct. In the critical care areas where patients may receive numerous continuous IV medication drips that might not all be compatible infusing through the same site, a multiple-port central venous access device can provide the best option. E. This is correct. Patients who are unstable and require rapid administration of medications require reliable IV access that might not be available with peripheral IV lines, and central venous access may be the best option.
The nurse administers a blood transfusion to a patient who begins to experience itching and shortness of breath. The nurse notes the patient has hives and facial flushing. Which is the priority action by the nurse? A. Monitoring vital signs B. Stopping the transfusion C. Elevating the head of the bed D. Administering prescribed antihistamine
B A. Although monitoring the patient's vital signs is an appropriate nursing action, this is not the priority action by the nurse. When in distress the priority is not to assess. B. The priority intervention in this situation is to stop the transfusion and notify the healthcare provider. C. Although this may be an appropriate intervention given the patient is experiencing dyspnea, this is not the priority action. The nurse stops the transfusion because the patient is likely experiencing an allergic reaction. D. Although administering the prescribed antihistamine is an appropriate intervention, this is not the priority. The priority action is to stop the transfusion and notify the healthcare provider.
Which component should the nurse anticipate will be prescribed for a patient who is not responding to crystalloids for volume expansion? A. Platelets B. Albumin C. Fresh frozen plasma D. Packed red blood cells
B A. Platelets are administered for patients who are bleeding as a result of thrombocytopenia or platelet abnormalities. B. Albumin is administered for volume expansion when crystalloid solutions are not adequate. C. Fresh frozen plasma is anticipated for a patient with a deficiency of plasma coagulation factors. D. Packed red blood cells are anticipated for a patient with acute or chronic blood loss and for patients diagnosed with anemia.
The nurse is caring for a patient who needs to have a peripheral intravenous catheter placed. When the patient requests to have the intravenous (IV) started in the foot, what is the best response by the nurse? A. "There is an increased risk of infection if an IV is started in your feet or legs." B. "There is an increased risk of a clot or inflammation if an IV is started in your foot." C. "Placing an IV in your foot decreases blood flow to your feet." D. "Placing an IV in your foot is more painful."
B A. There is an increased risk of thrombophlebitis, not infection. B. Veins in the lower extremities are not recommended for infusion therapy in the adult patient because of the high risk for thrombophlebitis. C. Placing an IV in the foot increases the risk of thrombophlebitis but does not impact arterial blood flow to the lower extremities. D. Placing an IV in the foot does not produce any difference in pain compared with the upper extremities.
The nurse provides care to several patients on a medical-surgical unit. Which situation requires the nurse to follow up with the healthcare provider before administering the prescribed treatment? A. The patient who requires volume expansion and who is prescribed albumin B. The patient diagnosed with thrombocytopenia who is prescribed fresh frozen plasma C. The patient diagnosed with symptomatic anemia who is prescribed packed red blood cells D. The patient diagnosed with neutropenia and infection that is resistant to antibiotics who is prescribed granulocytes
B A. Volume expansion when crystalloid solutions are not adequate necessitates an albumin transfusion. B. Bleeding caused by thrombocytopenia or platelet abnormalities is treated with a platelet transfusion, not a fresh frozen plasma transfusion. C. Symptomatic anemia along with acute and chronic blood loss is treated with a packed red blood cell transfusion. D. Neutropenia with infection unresponsive to appropriate antibiotics is treated with a granulocyte transfusion.
The nurse prepares to initiate intravenous (IV) access for an older adult patient who requires a blood transfusion. Which gauge needle is best for the nurse to use for this procedure? A. 18 B. 20 C. 22 D. 24
B A. Although an 18-gauge catheter is appropriate for the administration of blood, this is not the best choice given the patient's age. B. A 20-gauge catheter is appropriate for blood transfusion. Because the patient is an older adult, this is the best choice for the nurse to use for this procedure. C. A 22-gauge catheter is appropriate for continuous or intermittent infusions in small veins but too small for blood transfusion. D. A 24-gauge catheter is appropriate for continuous or intermittent infusions in fragile veins but too small for blood transfusion.
The nurse educator is developing a class on different types of intravenous catheters for an orientation for new staff. The nurse includes which types of catheters as examples of central venous devices? Select all that apply. A. Midline catheters B. PICC lines C. 20-gauge over-the-needle IVAD D. Implanted ports E. Butterfly catheters
B, D A. This is incorrect. Midline catheters are a type of infusion device that are inserted in a peripheral vein in the upper extremities with tips that terminate distal to the shoulder in either the basilica, cephalic, or brachial vein. Midlines are appropriate for therapies expected to last between 1 and 4 weeks. B. This is correct. Types of IVADs used to obtain central venous access include nontunneled percutaneous central catheters, tunneled catheters, implanted ports, and peripherally inserted central catheters (PICCs). C. This is incorrect. A 20-gauge over-the-needle IVAD is a type of peripheral intravenous catheter and is not used for central venous access. D. This is correct. Types of IVADs used to obtain central venous access include nontunneled percutaneous central catheters, tunneled catheters, implanted ports, and peripherally inserted central catheters (PICCs). E. This is incorrect. The steel-winged device (often referred to as a butterfly because of the appearance of wings on each side of the needle) is indicated only for short-term or single-dose therapy because the rigid steel needle is more likely to puncture the vein and lead to fluid or medication leaking out of the vein. This is not a central venous catheter.
The nurse is reviewing new healthcare provider orders on a patient admitted for treatment of severe dehydration. The patient's serum osmolality is 300 mOsm/kg. It is a priority for the nurse to follow up with the provider if which solution is ordered? A. 5% Dextrose in lactated Ringer's solution (D5LR) B. Dextrose 5% in 0.45% normal saline C. 0.45% Normal saline D. Dextrose 5% in 0.9% normal saline
C A. 5% Dextrose in lactated Ringer's solution (D5LR) is a hypertonic fluid that is indicated in patients with severe dehydration because it promotes fluid to move into the intravascular space. B. Dextrose 5% in 0.45% normal saline is a hypertonic fluid that is indicated in patients with severe dehydration because it promotes fluid to move into the intravascular space. C. 0.45% Normal saline is not the best solution in this situation because the patient is in need of replacement of intravascular volume. Because this solution is hypotonic, it would cause fluid to move from the intravascular space into the both the intracellular and interstitial spaces. D. Dextrose 5% in 0.9% normal saline is a hypertonic fluid that is indicated in patients with severe dehydration because it promotes fluid to move into the intravascular space.
In monitoring a patient receiving a blood transfusion, the nurse correlates which clinical manifestation as indicative of a hemolytic transfusion reaction? A. Increased blood pressure B. Itching C. Fever D. Facial flushing
C A. Hypotension is a clinical manifestation of a hemolytic transfusion reaction. B. Itching is a clinical manifestation of an allergic transfusion reaction. C. Fever is a clinical manifestation of a hemolytic transfusion reaction. D. Facial flushing is a clinical manifestation of an allergic transfusion reaction.
The nurse is caring for a patient who is to have a peripherally inserted central catheter (PICC) line inserted tomorrow. Because the patient's current peripheral access line is infiltrated and needs to be restarted, which site would the nurse avoid using? A. Radial vein B. Cephalic vein C. Median cubital vein D. Dorsal metacarpal veins
C A. The radial vein can be used because the veins used for peripherally inserted central catheter (PICC) insertion are usually the larger veins in the upper extremities. If infusion therapy using short peripheral therapy with repeated venipunctures has compromised these veins, PICC placement is much more difficult. B. The cephalic vein can be used because the veins used for PICC insertion are usually the larger veins in the upper extremities. If infusion therapy using short peripheral therapy with repeated venipunctures has compromised these veins, PICC placement is much more difficult. C. The median cubital vein, a larger vein in the upper extremity, is often used for PICC lines, so the nurse should attempt to avoid this site to maintain it for the central line. D. The dorsal metacarpal veins can be used because the veins used for PICC insertion are usually the larger veins in the upper extremities.
The patient who has been receiving Total Parenteral Nutrition (TPN) is being tapered from this therapy. It is important for the nurse to monitor for which complication if the solution is discontinued too rapidly? A. Hyperkalemia B. Hypernatremia C. Hypoglycemia D. Hypocalcemia
C A. There is no risk of changes in potassium levels related to tapering of TPN. B. There is no risk of changes in sodium levels related to tapering of TPN. C. Because of the high concentrations of dextrose, TPN therapy is initiated and discontinued gradually. If the TPN solution is abruptly stopped, the patient may experience hypoglycemia because the body needs time to adjust to the decreased glucose in the solution. D. There is no risk of changes in calcium levels related to tapering of TPN.
The nurse is initiating intravenous (IV) therapy for an adult patient who requires IV fluid infusion for 2 to 3 days and might require blood administration. Which would the nurse choose as the best option for IV catheterization? A. Butterfly B. Midline catheter C. Short over-the-needle catheter D. Implantable venous access device
C A. This steel-winged device, often referred to as a butterfly because of the appearance of wings on each side of the needle, is indicated only for short-term or single-dose therapy because the rigid steel needle is more likely to puncture the vein and lead to fluid or medication leaking out of the vein. B. Midline catheters are inserted in a peripheral vein in the upper extremities with tips that terminate distal to the shoulder in either the basilica, cephalic, or brachial vein. Midlines are appropriate for therapies expected to last between 1 and 4 weeks. C. The short over-the-needle IV catheter would be the best choice because the needle is removed and only the catheter remains in place, so it is more likely to last for 2 days without infiltrating. D. Implantable venous access devices are used when IV fluid needs are anticipated for several months.
The nurse anticipates which fluid movement when administering an isotonic IV fluid to a patient? A. Fluid moves from the cells into the intravascular space B. Fluid moves from the intravascular space into the intracellular space C. Causes no or equal movement of fluid into or out of cells D. Fluid moves from the intravascular space into the interstitial spaces
C A Hypertonic solutions have concentrations higher than plasma and cause fluid to move from the cells into the intravascular space. B Hypotonic solutions have a lower solution concentration than plasma and cause fluid to move from the intravascular space into both the intracellular and interstitial spaces. C Isotonic solutions have the same or nearly the same osmolarity as plasma and cause no movement of fluid into or out of cells. Isotonic solutions remain in the extracellular compartment in either the intravascular or interstitial compartments. D Hypotonic solutions have a lower solution concentration than plasma and cause fluid to move from the intravascular space into both the intracellular and interstitial spaces.
Which intravenous (IV) fluid should the nurse prepare when a patient requires a hypotonic solution? A. 0.9% Normal saline B. 5% Dextrose in water C. 0.33% Sodium chloride D. 5% Dextrose in lactated Ringer's
C A. 0.9% Normal saline is an isotonic solution. B. 5% Dextrose in water is a hypotonic solution. C. 0.33% Sodium chloride is a hypotonic solution. D. 5% Dextrose in lactated Ringer's is a hypertonic solution.
Which component should the nurse anticipate will be prescribed for a patient with an elevated prothrombin time (PT) and international normalized ratio (INR) who is at an increased risk for bleeding? A. Platelets B. Albumin C. Fresh frozen plasma D. Packed red blood cells
C A. Platelets are administered for patients who are bleeding as a result of thrombocytopenia or platelet abnormalities. B. Albumin is administered for volume expansion when crystalloid solutions are not adequate. C. Fresh frozen plasma is anticipated for a patient with a deficiency of plasma coagulation factors. D. Packed red blood cells are anticipated for a patient with acute or chronic blood loss and for patients diagnosed with anemia.
In monitoring a patient's intravenous (IV) site, the nurse correlates which findings to an infiltration? Select all that apply. A. Redness at the insertion site B. Purulent discharge the insertion site C. Leaking of fluid from the insertion site D. Blanched skin near the insertion site E. Skin cool to touch near the insertion site
C, D, E A. This is incorrect. Redness is seen in patients with phlebitis. Phlebitis, inflammation of the vein, is characterized by pain and erythema along the vein. B. This is incorrect. Purulent drainage around the site is indicative of an infectious or inflammatory process. C. This is correct. Infiltration occurs when solution or medication is inadvertently infused into the tissue surrounding the vein. Clinical manifestations of infiltration include blanched skin, skin cool to the touch, edema, unexpected pain or burning at the insertion site or along the path of the vein, and leaking of fluid from the insertion site. D. This is correct. Infiltration occurs when solution or medication is inadvertently infused into the tissue surrounding the vein. Clinical manifestations of infiltration include blanched skin, skin cool to the touch, edema, unexpected pain or burning at the insertion site or along the path of the vein, and leaking of fluid from the insertion site. E. This is correct. Infiltration occurs when solution or medication is inadvertently infused into the tissue surrounding the vein. Clinical manifestations of infiltration include blanched skin, skin cool to the touch, edema, unexpected pain or burning at the insertion site or along the path of the vein, and leaking of fluid from the insertion site.
The nurse correlates the administration of which blood component to the patient with acute blood loss? A. Platelets B. Albumin C. Fresh frozen plasma D. Packed red blood cells
D A. Platelets are administered for patients who are bleeding as a result of thrombocytopenia or platelet abnormalities. B. Albumin is administered for volume expansion when crystalloid solutions are not adequate. C. Fresh frozen plasma is anticipated for a patient with a deficiency of plasma coagulation factors. D. Packed red blood cells are anticipated for a patient with acute or chronic blood loss and for patients diagnosed with anemia.
The nurse is administering a blood transfusion to an adult patient. The patient reports feeling cold and is shivering 15 minutes after the initiation of the transfusion. The patient's blood pressure has decreased since the last assessment. Which is the nurse's priority action? A. Slowing the infusion rate and notifying the healthcare provider B. Slowing the infusion rate and continuing to monitor the blood pressure every 5 minutes C. Stopping the blood infusion, and infusing normal saline through the existing intravenous (IV) tubing D. Stopping the blood infusion, removing the tubing from the IV catheter, and replacing it with normal saline
D A. The patient is demonstrating clinical manifestations of a transfusion reaction, and the transfusion must be stopped. Then the provider can be contacted. B. The patient is demonstrating clinical manifestations of a transfusion reaction, and the transfusion must be stopped. The patient will need to be continuously monitored, but stopping the transfusion is the priority action. C. Stopping the blood infusion and running saline through the blood tubing will administer the blood found in the tubing and could make the transfusion reaction worse. D. The nurse should completely discontinue the blood infusion, disconnecting the tubing from the IV catheter and placing normal saline or the ordered solution infusing before beginning the blood infusion with new tubing.
