NUR172 Exam 1

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.

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.

The nurse is capping a client's IV line for intermittent use in preparation for the administration of an antibiotic. After inspecting the site, what will the nurse do next?

Close the clamp on the current administration set

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 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

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 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 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?

Shortness of breath.

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

Which hospitalized clients are good candidates for capping of an existing intravenous line for intermittent use? Select all that apply. (a) Client who needs infusions of an antibiotic only every 12 hours (b) Client who no longer requires intravenous infusions (c) Client who is only receiving fluids at a keep-vein-open rate (d) Client receiving a continuous infusion of normal saline at 60 mL/hour (e) Client who is tolerating clear liquids

a,b,c

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

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

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?

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

The nurse is capping an intravenous (IV) line for intermittent use. Place in order how the nurse will perform these actions. Use all options. (a) Flush the tubing slowly, over one minute, with a sterile saline filled syringe. (b) Reclamp the extension tubing and loop it near the entry site, securing it with tape. (c) Insert the saline flush syringe into the needleless connector or end cap on the extension tubing. (d) Aspirate the catheter for positive blood return by gently pulling back on the syringe. (e) Scrub the needleless connector or end cap on the extension tubing with an antimicrobial swab.

e,c,d,a,b