Intravenous Therapy
112) A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous solution will most likely be prescribed for this client? 1. 5% dextrose in lactated ringer's 2. 0.33% sodium chloride (1/3 normal saline) 3. 0.225% sodium chloride (1/4 normal saline) 4. 0.45% sodium chloride (1/2 normal saline)
1) 5% dextrose in lactated ringers - For this client the goal of therapy is to expand intravascular volume as quickly as possible. In this situation the client will likely experience a decrease in intravascular volume from blood loss resulting in a decreased blood pressure
103) A client had a 1000 mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 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 (IV) bag has 400 mL remaining. The nurse should take which action first? 1. Slow the IV infusion 2. Sit the client up in the bed 3. Remove the IV catheter 4. Call the health care provider
1) Slow the IV infusion - The clients sxms are compatible with circulatory overload. The first action is to slow the infusion.
111) A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which action(s) in the care of this client? Select all that apply. 1. Remove the IV catheter at the site 2. Apply warm moist packs to the site 3. Notify the HCP 4. Start a new IV line in a proximal portion of the same vein 5. Document the occurrence, actions taken, and the client's response
1,2,3,5 - Phlebitis is an infalmmation of the vein that can occur from mechanical or chemical medication trauma. or from a local infection and can cause the development of a clot
104) The nurse has a prescription to hang at 1000 mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride. The nurse also needs to hang an IV infusion of piperacillin/ tazobactam. The client has one IV site. The nurse should plan to take which action first? 1. Start a second IV site 2. Check the compatibility of the medication and the IV fluids 3. Mix the prepackaged pipercillin/tazobactaum per agency policy 4. Prime the tubing with the IV souoution and back prime the medication
2) Check the compatibility of the medication and the IV fluids - When hanging an IV antibiotic the nurse should first check compatibility of the medication and the IV fluids currently prescribed. If incompatible then a second IV site would be started
115) Intravenous IV fluids have been infusing at 100 ml/hr via a central line catheter in the right internal jugular for approx 24 hours to increase urine output and maintain the clients blood pressure. Upon entering the clients room the nurse notes that the client is breathing rapidly and coughing. For which additional signs of complication should the nurse assess based on the previously known data? 1) Excessive bleeding 2) Crackles in the lungs 3) Incompatibility of the infusion 4) Chest pain radiating to the left arm
2) Crackles in the lungs - Circulatory fluid overload is a complication of IV therapy signs include rapid breathing, dyspnea, a moist cough, and crackles . Blood pressure and heart rate also increase if overload is present.
113) The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instructions if the client made which statement? 1. "I need to wear a Medic-Alert tag or bracelet." 2. "I need to restrict my activity while this catheter is in place." 3."I need to keep the insertion site protected when in the shower or bath." 4) I need to check the markings on the catheter each time the dressing is changed.
2) I need to restrict my activity while this catheter is in place - The client should be taught that only minor activity restrictions apply with this type of catheter . The client should carry or wear and medic alert ID and should protect the site during bathing to prevent infection.
109) The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action? 1. Obtain a new IV bag 2. Obtain new IV tubing 3. Wipe the spike end of the tubing with betadine 4. Scrub the spike end of the tubing with an alcohol swab
2) Obtain new IV tubing - The nurse should obtain new IV tubing because contamination has occurred and could cause systemic infection to the client.
108) The nurse is assessing a clients peripheral IV site after completion of a vancomyocin infusion and notes that the area is reddend warm painful and slightly edematous proximal to the insertion point of the IV catheter. At this time which action by the nurse is best? 1) Check for the presence of blood return 2) remove the IV site and restart at another site 3) Document the findings and continue to monitor the IV site 4) Call the HCP and request that the vancomyocin be given orally.
2) Remove the IV site and restart at another site - Phlebitis at an IV site can be distinguished by client discomfort at the site and by redness warmth and swelling proximal to the catheter. If this occurs the IV site should be removed and insert a new IV line at a different site in a vein other than the one that has developed phlebitis.
106) The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. Which assessment findings are consistent with infiltration? Select all that apply. 1. Pain and erythema 2. Pallor and coolness 3. Numbness and pain 4. Edema and blanched skin 5) Formation of a red streak and purulent drainage
2,3,4 - An infiltrated IV line is one that has dislodged from the vein and is lying in suqutaneous tissue. Pallor coolness edema pain numbness and blanched skin are the results of IV fluid being deposited into subq tissue
114) A client has just undergone insertion of a central venous catheter at the bedside under ultrasound. The nurse would be sure to check which results before initiating the flow rate of the client's intravenous (IV) solution at 100 mL/hr? 1. serum osmolality 2. serum electrolyte levels 3. Intake and output records 4. Chest radiology results
4) Chest radiology results - Before beginning administration of IV solution's the nurse should assess whether the chest radiology results reveal that the central catheter is in the proper place.
107) The nurse is inserting an intravenous line into a client's vein. After the initial stick, the nurse would continue to advance the catheter in which situation? 1. The catheter advances easily 2. The vein is distended under the needle 3. The client does not complain of discomfort 4. Blood return shows in the backflash chamber of the catheter
4) Blood return shows in the backflash chamber of the catheter - The IV catheter has entered the lumen of the vein successfully when blood backflash shows in the IV catheter.
110) A health care provider has written a prescription to discontinue an intravenous (IV) line. The nurse should obtain which item from the unit supply area for applying pressure to the site after removing the IV catheter? 1. Elastic wrap 2. Betadine swab 3. Adhesive bandage 4. Sterile 2x2 gauze
4) Sterile 2X2 gauze - A dry sterile dressing such as a sterile 2x2 gauze is used to apply pressure to the dc'd IV site. This material is absorbent sterile and non-irratating
105) 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 1100 marking at the 500 mL level. The nurse should place the mark for 1200 at which numerical level (mL) on the time tape? _____ mL
A: 375 ml - If the IV is scheduled to run over 8 hours the hourly rate is 125 ml/hr