Chapter 15 Quiz
The nurse is inserting a peripheral intravenous (IV) catheter. Which client statement is of greatest concern during this procedure? "I hate having IVs started." "It hurts when you are inserting the line." "My hand tingles when you poke me." "My IV lines never last very long."
"My hand tingles when you poke me." The client's statement about a tingling feeling indicates possible nerve puncture and is of greatest concern to the nurse. To avoid further nerve damage, the nurse should stop immediately, remove the IV catheter, and choose a new site.Statements such as, "I hate having IVs started," "It hurts when you are inserting the line," and "My IVs never last very long," are addressed with teaching about the importance of proper protection of the site.
A 22-year-old client presents with appendicitis and is preparing for surgery. What gauge catheter will the ED nurse select for this client? 24 22 18 14
18 An 18-gauge catheter is the size of choice for clients who will undergo surgery. If they need to receive fluids rapidly, or if they need to receive more viscous fluids (such as blood or blood products), a lumen of this size would accommodate those needs.Neither a 24-gauge nor a 22-gauge catheter is an appropriate size (too small) for clients who will undergo surgery. If it becomes necessary to administer fluids to the client rapidly, another IV would be needed with a larger needle—18, for example. Administering through the smallest gauge necessary is usually best practice, unless the client may be going into hypovolemic status (shock). A 14-gauge catheter is an extremely large-gauge needle that is very damaging to the vein.
A client who takes corticosteroids daily for rheumatoid arthritis requires insertion of an IV catheter to receive IV antibiotics for 5 days. Which type of IV catheter does the charge nurse teach the new nurse to use for this client? -Midline catheter -Tunneled percutaneous central catheter -Peripherally inserted central catheter -Short peripheral catheter
Midline catheter For a client with fragile veins (which occur with long-term corticosteroid use) and the need for a catheter for 5 days, the midline catheter is the best choice.Tunneled central catheters usually are used for clients who require IV access for longer periods. Peripherally inserted central catheters usually are used for clients who require IV access for longer periods. A short peripheral catheter is likely to infiltrate before 5 days in a client with fragile veins, requiring reinsertion.
The nurse is preparing to insert a peripheral venous catheter. What action will the nurse take? Palpate for hardness of a vein. Use the client's dominant arm for insertion. Select the most distal site. Look near the elbow joint first.
Select the most distal site. The nurse will choose the most distal site and make all subsequent venipunctures proximal to previous sites. The nurse will not palpate for hard or cordlike veins as these are not ideal for cannulation. The nurse will use the client's nondominant arm and avoid areas of joint flexion.
The nurse is teaching a client who is being discharged about care for a peripherally inserted central catheter (PICC) line. Which client statement indicates a need for further education? "I can continue my 20-mile (32-km) running schedule as I have in the past." "I can still go about my normal activities of daily living." "I have less chance of getting an infection because the line is not in my hand." "The PICC line can stay in for months."
"I can continue my 20-mile (32-km) running schedule as I have in the past." The statement by the client stating that his or her normal running schedule can continue indicates a need for further education. Excessive physical activity can dislodge the PICC or lead to catheter occlusion and should be avoided.Clients with PICCs should be able to perform normal activities of daily living. PICCs have lower complication rates because the insertion site is in the upper extremity. The dry skin of the arm has fewer types and numbers of microorganisms, leading to lower rates of infection. PICC lines can be used long term (months).
The nurse is starting a peripheral IV catheter on a client who was recently admitted. What actions does the nurse perform before insertion of the line? (Select all that apply.) - Apply povidone-iodine to clean skin, dry for 2 minutes. -Clean the skin around the site. - Prepare the skin with 70% alcohol or chlorhexidine. -Shave the hair around the area of insertion. -Wear clean gloves and touch the site only with fingertips after applying antiseptics.
-Apply povidone-iodine to clean skin, dry for 2 minutes. -Clean the skin around the site. -Prepare the skin with 70% alcohol or chlorhexidine. Povidone-iodine (Betadine) is applied to the selected insertion site before insertion. The solution is allowed to dry, which takes about 2 minutes. The insertion site should be cleansed before the antiseptic skin preparations are completed. After soap and water cleansing, prepping with 70% alcohol or chlorhexidine is done.Clipping, rather than shaving, hair around the selected IV site is done. Shaving is abrasive and makes the skin more vulnerable to infection (i.e., microbial invasion). The insertion site should not be palpated again after it has been prepped; this mistake is frequently made with IV starts.
Which client does the charge nurse on a medical-surgical unit assign to the LPN/LVN? -A client who has a diltiazem IV infusion being titrated to maintain a heart rate between 60 and 80 beats/min. -A client admitted for hyperglycemia who has an IV insulin drip and needs frequent glucose checks. -An older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours. -A client receiving blood products after excessive blood loss during surgery.
An older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours. The older client admitted for confusion with a heparin lock is the most stable and requires basic monitoring of the IV site for common complications such as phlebitis and local infection, which would be familiar to an LPN/LVN.The client with a diltiazem IV infusion, the client with an IV insulin drip, and the client receiving blood products all are not stable and will require ongoing assessments and adjustments in IV therapy that should be performed by an RN.
A client is being admitted to the burn unit from another hospital. According to the client's medical record, the client has an intraosseous IV that was started 2 days ago. Which nursing action is most appropriate? Anticipate an order to discontinue the intraosseous IV. Call the previous hospital to verify the date. Immediately discontinue the intraosseous IV. Start an epidural IV.
Anticipate an order to discontinue the intraosseous IV. The admitting nurse would first anticipate an order to discontinue the intraosseous IV and then start an epidural IV. The intraosseous route should be used only during the immediate period of resuscitation and should not be used for longer than 24 hours. Alternative IV routes, such as epidural access, should then be considered for pain management.The nurse should know what to do in this client's situation without contacting the previous hospital. Other client data, such as the date and time that the burn occurred, should validate the date and time of insertion of the IV. Discontinuing the IV is not the priority in this situation—the client is in a precarious fluid balance situation. One IV access should not be stopped until another is established. This type of IV is not used for long-term therapy; an action must be taken.
The nurse who is starting the shift finds a client with an IV that is leaking all over the bed linens. What will the nurse do first? Assess the insertion site. Check connections. Check the infusion rate. Discontinue the IV and start another.
Assess the insertion site. The initial response by the nurse is to assess the insertion site. The purpose of this action is to check for patency, which is the priority. IV assessments typically begin at the insertion site and move "up" the line from the insertion site to the tubing, to the tubing's connection to the bag.Checking the IV connection is important, but is not the priority in this situation. Checking the infusion rate is not the priority. Discontinuing the IV to start another may be required, but it may be possible to "save" the IV, and the problem may be positional or involve a loose connection.
The primary health care provider has prescribed 1 L of D5NS to infuse at a rate of 125 mL/hr. The nurse begins the infusion at 0700 (7 a.m.). When will the nurse anticipate completion of the infusion? A. 1300 hours (1 p.m.) B. 1500 hours (3 p.m.) C. 1900 hours (7 p.m.) D. 2100 hours (9 p.m.)
B. 1500 hours (3 p.m.) The nurse will anticipate completion of the infusion at 1500 hours (or 3 pm). To calculate this the nurse will take the total volume of 1000 mls and divide by the rate 125 ml/hr which equals 8. Thus, the infusion will be complete in 8 hours. If the nurse begins the infusion at 0700, in 8 hours it will be 1500 hours (or 3 pm).
A client had a 20-gauge short peripheral catheter (SPC) inserted for antibiotic administration 48 hours ago. Which nursing intervention is appropriate? A. Discontinue the SPC. B. Relocate the SPC for infection control. C. Assess the SPC for redness, swelling, or pain. D. Change the occlusive dressing covering the SPC.
C. Assess the SPC for redness, swelling, or pain. It is important for the nurse to assess the SPC for signs of infection or infiltration which include redness, swelling, and pain. The nurse would not discontinue the SPC as there is no indication in the stem that the client has concluded IV therapy. It is no longer common practice to relocate SPCs based on a 48-hour time frame. If the site assessed is free from signs of infection or infiltration, relocating the site is not warranted. Changing the dressing should only be done when relocating an IV or when the dressing is visible soiled.
An older adult client receiving an infusion of 5% dextrose in 0.9% normal saline at 150 mL/hour has developed shortness of breath with a decrease in oxygen saturation to 86%. What is the priority nursing intervention? A. Notify the health care provider B. Place the client on oxygen C. Sit the client upright in bed D. Assess the client's lung sounds
C. Sit the client upright in bed Because the client is short of breath, the priority action that can be done immediately is to sit the client upright in bed. Assessing the lung sounds can occur after sitting the client upright. Use of oxygen and contacting the healthcare provider will follow the priority action. The rate of infusion is likely too fast for an older adult client which has created fluid build-up. The nurse will anticipate fine crackles in the lung bases and decrease in the IV flow rate and notify the health care provider.
The nurse is admitting clients to the same-day surgery unit. Which insertion site for routine peripheral venous catheters will the nurse choose most often? Back of the hand Cephalic vein of the forearm Palmer side of the wrist Subclavian vein
Cephalic vein of the forearm The cephalic vein of the forearm is the insertion site chosen most often. For same-day surgery, the cephalic or basilic vein allows insertion of a larger IV catheter while allowing movement of the arm without impairing intravenous flow.Peripheral venous catheters should never be inserted into the back of the hand in an older adult because the veins are brittle. Peripheral venous catheters are not inserted into the palmar side of the wrist because the median nerve is located close to this area. Catheters are typically inserted into the subclavian vein by the health care provider, not by the nurse.
The nurse is administering a drug to a client through an implanted port. Before giving the medication, what will the nurse do to ensure safety? Administer 5 mL of a heparinized solution. Check for blood return. Flush the port with 10 mL of normal saline. Palpate the port for stability.
Check for blood return. To ensure safety, before a drug is given through an implanted port, the nurse must first check for blood return. If no blood return is observed, the drug should be held until patency is reestablished.If no blood return is observed, the drug should be held until patency is re-established. Ports are flushed with heparin or saline after, rather than before, use. The port is palpated for stability, but this action alone does not ensure the client's safety.
The nurse is documenting peripheral venous catheter insertion for a client. What will the nurse include in the note? (Select all that apply.) Client's name and hospital number Client's response to the insertion Date and time inserted Type and size of device Type of dressing applied Vein used for insertion
Client's response to the insertion Date and time inserted Type and size of device Type of dressing applied Vein used for insertion The client's ability to adapt to interventions, such as IV insertion, should be noted when the intervention is performed. The date and time of the insertion are important data. IV sites need to be routinely monitored and changed at prescribed intervals per facility policy. It is important to note the device used (often the brand name is given), as well as all specifics such as needle or cannula length, gauge, and material (Teflon). It is necessary to describe the dressing applied, and the vein used should be noted.The client's name and hospital number should be on the medical record, but the nurse makes certain that the information is recorded in the correct medical record.
The nurse is checking an IV fluid order and questions accuracy. What nursing action is appropriate? Ask the charge nurse about the order. Contact the prescribing health care provider. Contact the pharmacy for clarification. Start the fluid as ordered.
Contact the prescribing health care provider. First, the nurse will contact the health care provider who ordered the fluids. The nurse is legally and professionally responsible for accuracy and has the duty to verify the order with the health care provider who ordered it.The nurse can consult the charge nurse, but this is not the definitive action that the nurse should take. Contacting the pharmacy is not the best action that the nurse should take. Giving (or starting) the fluid when the order is questionable is not appropriate and could possibly harm the client.
The nurse is to administer a unit of whole blood to a postoperative client. What will the nurse do to ensure the safety of the blood transfusion? -Ask the client to both say and spell his or her full name before starting the blood transfusion. -Ensure that another qualified health care professional checks the unit before administering. -Check the blood identification numbers with the laboratory technician at the blood bank at the time it is dispensed. -Make certain that an IV solution of 0.9% normal saline is infusing into the client before starting the unit.
Ensure that another qualified health care professional checks the unit before administering. To ensure safety, blood must be checked by two qualified health care professionals, usually two registered nurses.Administering an incorrectly matched unit of blood creates great consequences for the client and is considered to be a sentinel event. It requires a great amount of follow-up and often changing of policies to improve safety. The Joint Commission requires that the client provide two identifiers, but they are the name and date of birth or some other identifying data, depending on the facility; saying and spelling the name is only one identifier. Although a check is provided at the blood bank, this is not the one that is done before administration to the client. Clients do need to have normal saline running with blood, but this is not considered to be part of the safety check before administration of blood and blood products.
A male client is seen in the emergency department (ED) with pain, redness, and warmth of the right lower arm. The client was in the ED last week after an accident at work where he received 12 hours of IV fluids. On assessment, the nurse notes the presence of a palpable cord 1 inch (2.5 cm) in length and streak formation. How will the nurse document the assessment? Grade 1 phlebitis Grade 2 phlebitis Grade 3 phlebitis Grade 4 phlebitis
Grade 3 phlebitis Grade 3 phlebitis indicates pain at the access site with erythema and/or edema and streak formation with a 1' palpable cord.Grade 1 indicates only erythema with or without pain; the client has additional symptoms. Grade 2 indicates only pain at the access site with erythema and/or edema; the client has additional symptoms. Grade 4 indicates pain at the access site with erythema and/or edema, streak formation, a palpable venous cord longer than 1 inch (2.5 cm), and purulent drainage. No purulent drainage is present in this client, and the palpable cord is 1 inch (2.5 cm) in length.
The nurse is teaching a course about the special needs of older adults receiving IV therapy. What teaching will the nurse include? Placement of the catheter on the back of the client's dominant hand is preferred. Skin integrity can be compromised easily by the application of tape or dressings. To avoid rolling the veins, a greater angle of 25 degrees between the skin and the catheter improves success with venipuncture. When the catheter is inserted into the forearm, excess hair should be shaved before insertion.
Skin integrity can be compromised easily by the application of tape or dressings. Skin in older adults tends to be thin. Tape or dressings used with IV therapy can compromise skin integrity.Placement on the back of the dominant hand is contraindicated because hand movement can increase the risk of catheter dislodgement. An angle smaller than 25 degrees is required for venipuncture success in older adults. This technique is less likely to puncture through the older adult client's vein. Clipping, and not shaving, the hair around the insertion site typically is necessary only for younger men.
When flushing a client's central line with normal saline, the nurse feels resistance. Which action will the nurse take first? -Decrease the pressure being used to flush the line. -Obtain a 10-mL syringe and reattempt flushing the line. -Stop flushing and try to aspirate blood from the line. Correct -Use "push-pull" pressure applied to the syringe while flushing the line.
Stop flushing and try to aspirate blood from the line. The nurse's first step is to stop flushing and try to aspirate blood from the line. If resistance is felt when flushing any IV line, the nurse should stop and further assess the line. Aspiration of blood would indicate that the central line is intact and is not obstructed by thrombus.Decreasing the pressure to flush the line is not appropriate. Continuing or reattempting to flush the line, or using a push-pull action on the syringe, might result in thrombus or injection of particulate matter into the client's circulation.
A client receiving gentamycin intravenously reports that the peripheral IV insertion site has become painful and reddened. What is the priority nursing action? A. Contact the primary health care provider B. Document findings in the electronic health record C. Change the IV site to a new location D. Stop the infusion of the drug
Stop the infusion of the drug The nurse needs to stop the infusion of the drug first because the IV site is likely infiltrated. Then documentation, notifying the primary health care provider, and starting a new IV can occur.
The nurse is revising an agency's recommended central line-associated bloodstream infection (CLABSI) bundle. Which actions decrease the client's risk for this complication? (Select all that apply.) -During insertion, draping just the area around the site with a sterile barrier -Removing the client's venous access device (VAD) when it is no longer needed -Making certain that observers of the insertion are instructed to look away during the procedure -Thorough hand hygiene before insertion -Using chlorhexidine for skin disinfection
-Removing the client's venous access device (VAD) when it is no longer needed -Thorough hand hygiene before insertion -Using chlorhexidine for skin disinfection As soon as the VAD is deemed unnecessary, it needs to be removed to reduce the risk for infection. Thorough handwashing is a key factor in insertion and maintenance of a central line device. Quick handwashing is not sufficient. Chlorhexidine is recommended for skin disinfection because it has been shown to have the best outcomes in infection prevention.During the insertion, the whole body (head to toe) of the client is draped with a sterile barrier. Draping only the area around the site will increase risk for infection. Looking away will not reduce the risk for infection. Reducing the number of people in the room and having everyone wear a mask will help reduce the risk for infection.
A client who is receiving intravenous antibiotic treatments every 6 hours has an intermittent IV set that was opened 20 hours ago. What action will the nurse take? Change the set immediately. Change the set in about 4 hours. Change the set in the next 12 to 24 hours. Nothing; the set is for long-term use.
Change the set in about 4 hours. Because both ends of the set are being manipulated with each dose, standards of practice dictate that the set should be changed every 24 hours, so the set should be changed in about 4 hours.It is not necessary to change out the set immediately, but it must be changed before the next 12 to 24 hours.
Which nursing assessment data indicate the need for immediate nursing intervention? -Client states, "It really hurt when the nurse put the IV in." -The vein feels hard and cordlike above the insertion site. -Transparent dressing was changed 5 days ago. -Tubing for the IV was last changed 72 hours ago.
The vein feels hard and cordlike above the insertion site. A hard, cordlike vein suggests phlebitis at the IV site and indicates an immediate need for nursing intervention. The IV should be discontinued and restarted at another site.It is common for IVs to cause pain during insertion. An intact transparent dressing requires changing only every 7 days. Tubing for peripheral IVs should be changed every 72 to 96 hours.
