IV Therapy
The primary care provider orders an IV of 5% dextrose in 1/2 normal saline (0.45% sodium chloride) to infuse over a 10-hour period. Which of the following actions should the nurse take? (Select all that apply.) a. Monitor intake and output (I&O) every shift. b. Monitor weight daily. c. Flush with heparin solution intermittently. d. Monitor lung sounds every 4 hours. e. Monitor IV site for infiltration. f. Monitor blood sugar levels.
1. Monitor intake and output (I&O) every shift. 2. Monitor IV site for infiltration. 3. monitor lung sounds every 4 hours *To monitor fluid overload, it is important to assess lung sounds and I&O. Monitoring the IV site for infiltration or phlebitis is also critical.
The nurse must assess for complications of IV therapy. Signs of common complications include (select all that apply) A. Swelling and coolness at the site B. Redness along the vein C. Pale skin at the insertion site D. Immobility of the extremity E. Erythema and tenderness
1. Swelling and coolness at the site 2. Redness along the vein 3. Pale skin at the insertion site 4. Erythema and tenderness *Swelling, coolness, or pale skin at the insertion site is a sign of an infiltration of a nonirritating IV fluid. Erythema and tenderness are signs of infiltration of an irritating medication or fluid. Redness along the vein can occur with a very irritating medication. Redness and tenderness could also signal a localized infection. (4) Use of an arm board could decrease the patient's mobility, but arm boards are generally not necessary if the IV is properly secured and if the antecubital site is avoided. (6) Vomiting and diarrhea are not usually directly associated with IV fluid therapy or catheter insertion.
A nurse is aware that for a patient with a continuous IV infusion running, the IV bag should be changed when only ______ mL of solution remains in the bag. a. 10 mL b. 25 mL c. 50 mL d. 100 mL
50 mL *When the container has only 50 mL of solution left, the next ordered solution is added to the setup and the flow begun to prevent air from entering the line.
The nurse takes into consideration that according to The Joint Commission, the first IV antibiotics order for a community acquired pneumonia must be administered within: a. 1 to 2 hours b. 2 to 4 hours c. 6 to 8 hours d. 24 hours
6 to 8 *The Joint Commission suggests that the first IV antibiotic administered for community acquired pneumonia be administered in the first 6 to 8 hours after admission.
The patient will need intravenous therapy for at least a week. The nurse would change the IV site every A. 24 hours B. 48-72 hours C. 12 hours D. 72-96
72-96 hours
The LVN/LPN is told by the RN to discontinue an IV line to the patient. The best nursing action is to: a. check the primary care provider's order. b. stop the IV flow by clamping the tubing securely. c. wash hands and don gloves. d. quickly withdraw the cannula and apply pressure.
check the primary care provider's order. *Checking the primary care provider's order will prevent inadvertently discontinuing the IV and having to restart it.
A nurse is monitoring the status of an older adult patient who is receiving IV therapy. Indicator of fluid volume overload is suspected when the nurse assesses: a. crackles in the lung fields. b. pulse rate of 64 beats/min, irregular. c. respirations of 16 breaths/min, regular. d. slight edema to the feet.
crackles in the lung fields *Fluid overload is signaled by crackles in the lung fields, increasing pulse rate, and shortness of breath.
After the piggyback infusion is finished, the nurse would FIRST A. flush the cannula with normal saline B. attach the next piggyback medication tubing C. disconnect the piggyback tubing D. cleanse the port on the prn device with alcohol
disconnect the piggyback tubing
The nurse would plan to get another nurse to try to obtain a successful venipuncture if the first nurse was not successful in: a. five attempts. b. three attempts. c. two attempts. d. one attempt.
two attempts *If the nurse cannot initiate a patent IV in two attempts, it is good judgment to ask another nurse to perform the task.
The nurse assisting in the initiation of a blood transfusion is aware that the only appropriate solution to infuse through a parallel infusion set before and after the transfusion is: a. 5% dextrose in water. b. 10% dextrose in water. c. lactated Ringer's solution. d. normal saline.
normal saline. *Normal saline is the only solution used in conjunction with infusion of a blood product.
A patient rings the call bell and states that the IV insertion site is painful. The site is reddened, warm, and swollen. The nurse assesses that the patient is most likely experiencing: a. bloodstream infection. b. catheter embolus. c. infiltration of the line. d. phlebitis.
phlebitis. *Phlebitis is caused by irritation of the vessel by the needle, cannula, medications, or additives to IV solution. Typical signs are erythema, warmth, swelling, and tenderness.
The patient complains that the IV site is stinging. It is not reddened or warm to the touch. He has been up and about and the flow rate has increased from where it was set. You should FIRST A. stop the infusion B. take the vital signs C. reset the drip rate D. change the IV site
reset the drip rate
When a patient receiving IV medication exhibits light headedness, tightness in the chest, flushed face, and irregular pulse, the nurse suspects: a. speed shock. b. drug allergy. c. fluid overload. d. air embolus.
speed shock *Light headedness, tightness in the chest, flushed face, and irregular pulse are all signs of speed shock. Speed shock is when a foreign substance is infused into the body rapidly. The infusion should be stopped, the primary care provider notified, and the patient monitored.
A patient complains of chills, back pain, and shortness of breath a few minutes after the blood infusion is started. The first thing the nurse should do is: a. slow down the blood infusion. b. stop the blood infusion and start the saline. c. monitor vital signs and call the primary care provider. d. start low flow oxygen as per facility protocol.
stop the blood infusion and start the saline. *If a transfusion reaction occurs, such as chills, back pain, and shortness of breath or itching, the nurse should stop the infusion and start the saline to keep the line open
Your patient is to receive intravenous therapy for several weeks. A PICC line is placed. Where would the nurse expect it to be inserted? A. the antecubital space B. the plantar aspect of the lower arm C. the basilic or cephalic vein of the upper arm D. above the wrist and below the elbow
the basilic or cephalic vein of the upper arm
A nurse takes a client's temperature before giving a blood transfusion. The temperature is 100 degrees F orally. The nurse reports the finding to the RN and anticipates that which of the following actions will take place? A. The transfusion will begin as prescribed B. The blood will be held and the physician will be notified C. The transfusion will begin after the administration of an antihistamine D. The transfusion will begin after the administration of 600 mg of acetaminophen
the blood will be held and the physician will be notified *If the client has a temperature of 100F or more, the unit of blood should be held until the PCP is notified and has the opportunity to give further prescriptions
The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item? A. vital signs B. skin color C. Oxygen saturation D. Latest hematocrit level
vital signs *A change in the vital signs may indicate that a transfusion reaction is occurring. The nurse assesses the client's vital signs before the procedure to obtain a baseline every 15 minutes for the first half hour after beginning the transfusion and every half hour thereafter. Skin color, oxygen saturation, and most recent hematocrit may be checked but are not the most important
A nurse accessing the injection port of the IV tubing will "scrub the hub" for: a. 5 seconds. b. 10 seconds. c. 15 seconds. d. 30 seconds
15 seconds *The hub of the injection port on a piggyback setup should be scrubbed for 15 seconds.
A patient has just undergone placement of a central venous catheter through the subclavian vein. When the placement is complete, the nurse should: a. hang the prescribed fluid at a rate of 1 mL/min. b. assess the quality of the breath sounds. c. note the length of the tubing. d. wait for the results of the chest radiograph before beginning fluids.
wait for the results of the chest radiograph before beginning fluids. *Correct placement of subclavian catheters must be verified by radiographic studies before any fluid is infused through them.
The order for the patient reads "D5W 1000 mL to follow the container that is hanging presently." There are 75 mL left in the container hanging. The nurse should A. hang the new container before the old one runs dry B. wait until another 25 mL have infused before hanging the new container C. hang the new container when the remaining fluid has infused D. hang the new container when there are 10 mL left in the container
wait until another 25 mL have infused before hanging the new container
Which of these clients is/are most likely to develop fluid (circulatory) overload? (select all that apply) A. A premature infant B. A 101-year-old man C. A client with heart failure D. A client with diabetes mellitus E. A client receiving renal dialysis F. A 29-year-old client with pneumonia
1`. A premature infant 2. A 101-year-old man 3. A client with heart failure 4. A client receiving renal dialysis *Clients with cardiac, respiratory, renal, or liver disease and older and very young children clients cannot tolerate an excessive fluid volume. The risk of fluid (circulatory) overload exists with these clients
A client is assisting with caring for a client who is receiving a unit of packed red blood cells (PRBCs). The nurse should tell the client that it is most important to report which sign(s) immediately? A. Sore throat or earache B. Chills, itching, or rash C. Unusual sleepiness or fatigue D. Mild discomfort at the catheter site
Chills, itching, or rash *The client is told to report chills, itching, or rash immediately because these could be signs of a possible transfusion reaction.
A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing? A. Uncaps the distal end of the tubing B. Uncaps the spike portion of the tubing C. Opens the roller clamp on the IV tubing D. Closes the roller clamp on the IV tubing
Closes the roller clamp on the IV tubing *The nurse should first clamp the tubing to prevent the solution from running freely through the tubing after it is attached to the IV bag. The nurse should next uncap the proximal (spike) portion of the tubing and attach it ti the IV bag. The IV bag is elevated, and the roller clamp is then opened slowly, and the fluid is allowed to flow through the tubing in a controlled fashion to prevent air from remaining in parts of the tubing
The nurse is doing a routine assessment of a client's peripheral intravenous (IV) infusion. The nurse is providing hygiene care to the client and should avoid which while changing the client's hospital gown? A. Using a hospital gown with snaps at the sleeves B. Disconnecting the IV tubing from the catheter in the vein C. Checking the IV flow rate immediately after changing the hospital gown D. Putting the bag and tubing through the sleeve, followed by the client's arm
Disconnecting the IV tubing from the catheter in the vein *The tubing should not be removed from the IV catheter. With each break in the system, there is an increased chance of introducing bacteria into the system, which can lead to an infection. Using gowns with snaps and inserting the IV bag and tubing throught the sleeve of the gown first are appropritate. The flow rate should be checked immediately after changing the hospital gown, because the position of the roller clamp may have been affected furing the change
A urse is collecting data from a client who is receiving IV therapy and reports pain in the arm, chills, and "not feeling well." The nurse notes warmth, edema, induration, and red streaking on the client's arm close to the IV insertion site. Which of the following actions should the nurse plan to take first? A. Obtain a specimen for culture B. Apply a warm compress C. Administer analgesics D. Discontinue the infusion
Discontinue the infusion *The greatest risk to this client is further injury to the irritated vein. the first action is to stop the infusion and remove the cathter to prevent further harm
The nurse is diong a routine assessment of a clients's peripheral intravenous (IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which has probably occurred? A. Phlebitis B. Infection C. Infiltration D. Thrombosis
Infiltration *An infiltrated IV is one that has dislodged fromthe vein and is lying in subcutaneous tissue. The pallow, coolness, and swelling are the result of IV fluid being deposited into the subcutaneous tissue. When the pressure in the tissue exceeds the pressure in the tubing, the flow of the IV solution will stop. The other options identify complications that are likely to be accompanied by warmth at the site rather than coolness
Which statement is true regarding giving drugs by the IV route? a. Intravenous drugs must go through first-pass metabolism to be absorbed. b. Intravenous drugs are deposited directly into the blood stream. c. Intravenous drugs have lower rates of adverse events. d. Intravenous drugs are less effective than oral drugs.
Intravenous drugs are deposited directly into the blood stream. *Drugs administered by the intravenous route are deposited directly into the bloodstream and have a higher incidence of chance for adverse events.
Which drug route would you expect to be the most rapidly absorbed? a. Subcutaneous injection b. Intravenous injection c. Rectal suppository d. Sublingual tablet
Intravenous injection
A patient is to have an IV insertion site changed. The current line is in the lower right forearm. Which location is contraindicated for the new site? a. Right upper forearm b. Right hand c. Left upper forearm d. Left hand
Right hand *A new IV site should not be placed distal to an old site; the right hand is distal to the right forearm, so it should not be used.
A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area? A. The pharmacy B. The laboratory C. The blood bank D. The risk-management department
The blood bank *The nurse prepares to return the blood transfusion bag containing any remaining blood to the blood bank. This allows the blood bank to complete any follow-up testing procedures that are needed after a transfusion reaction has been documented
A patient is admitted with a peripherally inserted central catheter (PICC). As part of standard care for this patient, the nurse should: a. obtain the patient's temperature every 2 hours. b. prepare to infuse fluids at high volumes. c. avoid taking blood pressures on the arm with the PICC line. d. have the catheter withdrawn while the patient is hospitalized.
avoid taking blood pressures on the arm with the PICC line *PICC lines are inserted by physicians or specially trained nurses, and they are used for long-term therapy; blood pressures are not taken in the arm that has the PICC line to avoid interfering with the function or the life of the catheter. Many times this catheter is used in home care.
During the first several days of TPN administration, it is especially important to check the patient's ________________.
blood glucose level
The nurse instills diluted medication in the portion of the controlled volume IV setup, which is called the ___________.
burette *The burette is the tube-like chamber that holds only about 150 mL of fluid with diluted medication.
The nurse observes that the insertion site of an IV catheter looks pale and puffy and the area feels cool to the touch. The initial action for the nurse should be to: a. discontinue the infusion and start a new IV site. b. apply warm compresses to the site. c. monitor the patient's temperature every 4 hours. d. call the primary care provider and report these findings.
discontinue the infusion and start a new IV site *Infiltration is the most common complication of IV therapy, and it occurs when fluid or medication leaks out of the vein and into the tissue. The infusion should be discontinued immediately and a new insertion site initiated. Signs are pale, cool skin that is edematous (puffy).
The nurse anticipates that the malnourished postoperative 70-year-old patient will receive an intravenous (IV) infusion of 5% dextrose in 0.45% saline, because it is: a. isotonic. b. hypotonic. c. hypertonic. d. total parenteral nutrition
hypertonic *5% Dextrose in 0.45% saline is a hypertonic or high molecular solution and is a frequent choice for postoperative maintenance fluid.
What solution can you not give to a child?
hypotonic
The nurse caring for a patient with an intermittent IV device should: a. attach continuous fluid infusion to the device. b. infuse saline or heparin solution to maintain patency. c. discontinue when the IV medication is finished. d. reduce patient activity to prevent dislodgement.
infuse saline or heparin solution to maintain patency. *The intermittent IV device should be flushed periodically with saline or heparin, depending on facility policy, to maintain patency, which allows more freedom of movement for the patient.
To facilitate the administration of an IV antibiotic every 6 hours to a patient who is ambulatory, well hydrated, and on a regular diet, the nurse would insert a(n): a. primary IV line. b. secondary IV line. c. intermittent infusion device. d. central venous line
intermittent infusion device. *Patients who do not require large amounts of fluid but receive intermittent IV medications benefit from an intermittent infusion device.
A patient receiving TPN fluid therapy experiences an air embolus in the central line. The nurse should immediately turn the patient onto the: a. right side and raise the head of the bed. b. right side and lower the head of the bed. c. left side and raise the head of the bed. d. left side and lower the head of the bed.
left side and lower the head of the bed *To anatomically minimize the risk of the air embolus reaching the lungs, the nurse should turn the patient onto the left side and lower the head of the bed. The primary care provider is notified immediately.
A patient has an order for an infusion of 5% dextrose in 0.45% sodium chloride at a rate of 100 mL/hr IV. The IV tubing has a drop factor of 15 gtt/mL. At how many drops per minute should the nurse regulate the infusion? a. 15 b. 17 c. 25 d. 33
25 *The formula for calculating IV flow rates is as follows: (Amount of solution in mL # of gtts/min)/Time in minutes (100 15)/60 = 1500/60 = 150/6 = 25 drops/min.
The next IV order for the patient reads "1000 mL D5W with 20 mEq of KCL to run over 8 hours." The drop factor is 15 gtt/mL. The correct flow rate per minute is ________ gtt/min.
31
When a patient is experiencing a life-threatening emergency, you may be given an order to give drug via which route? a. IV route b. IM route c. Rectal route d. Subcutaneous route
IV route
In which circumstance would the use of a burette be advised as a safety device? A. A trauma patient needs several units of packed red blood cells B. The patient needs IV fluids, but no infusion pump is available C. An infant is at risk for IV fluid volume overload D. A confused patient keeps trying to unplug the infusion pump
An infant is at risk for IV fluid volume overload *The burette provides a way to measure the exact amount of IV fluid that could flow into the infant. (1) The burette would not be used in the case of a trauma patient. (2) You could use a burette for a patient who needs IV fluids, but remember that the burette will hold a limited amount of fluid and you will have to refill the burette frequently, so it may cause more work. (4) If a patient unplugs an infusion pump, the pump is likely to continue on a battery. When the battery runs low, an alarm will begin to sound. If the battery depletes, the IV will not infuse. Use of a burette in this case serves no purpose.
A nurse is demonstrating how to insert an IV catheter. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure? A. "I will thread the needle all the way into the vein until the hub rests against the insertion site after I see a flashback of blood." B. "I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up." C. "I will apply pressure approximately 1.2 inches below the insertion site prior to removing the needle." D. "I will choose a vein inthe antecuvital fossa for IV insertion due to its size and easily accessible device."
"I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up." *Use a smooth, steady motion to insert the catheter through the skin at an angle of 10 to 30 degrees with the bevel up. This is the optimal angle for preventing the puncture of the posterior wall of the vein
During new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by an orientee indicates understanding of the preventative strategies? A. "I will leave the IV catheter in place after the client completes the course of IV antibiotics." B. "As long as I am working with the same client, I can use the same IV catheter for my second insertion attempt." C. "If my client needs to use the rest room, it would be safer to disconnect their IV infustion as long as I clean the injection port thoroughly with an antiseptic swab." D. "I will replace any IV catheter when I suspect contamination during insertion."
"I will replace any IV catheter when I suspect contamination during insertion." *Replace IV catheters when suspecting any break in surgical aseptic technique (in emergency insertions)
A 62-year old male patient with liver disease asks you why he is receiving a drug intravenously rather than by mouth. What is your best response? a. "Many oral drugs are inactivated as you get older." b. "Your liver disease impairs the transformation of a drug into its active form." c. "Intravenous drugs reduce toxicity to the liver through first-pass metabolism." d. "Individuals with liver disease have a genetic impairment that prevents drug activation."
"Your liver disease impairs the transformation of a drug into its active form." *Many drugs must be activated by enzymes before they can be used in the body. This biotransformation happens in the liver. Liver disease impairs this process
A nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride IV at 120 mL/hr. Which of the following statemtne by the client should alert the nurse to suspect fluid overload? A. "I feel lightheaded." B. "I feel as though my heart is racing." C. "I feel a little short of breath." D. "The nurse technician told me my blood pressure was 150/90." E. "I think my ankles are less swollen."
1. "I feel as though my heart is racing." 2. "I feel a little short of breath." 3. "The nurse technician told me my blood pressure was 150/90." *tachycardia due to the increased blood volume, which causes the heart rate to increase, shortness of breath or dyspnea due to the increased amount of fluid entering the air spaces int he lungs, which reduces the amount of circulating oxygen, and hypertension due to the increased blood volume, which causes the BP to increase are all manifestations of fluid overload
A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply) A. "The temperature around the IV site is cooler" B. "The rate of infusion increases" C. "The skin at the IV site is red" D. "The IV dressing is damp" E. "The tissue around the venipuncture site is swollen"
1. "The temperature around the IV site is cooler" 2. "The IV dressing is damp" 3. "The tissue around the venipuncture site is swollen" *A decrease in skin temperature around the site is a manifestation of infiltrating due to the IV solution entering the subcutaneous tissue around the venipuncture site *A damp IV dressing is a common finding with infiltration due to the IV solution entering the subcutaneous tissue and leaking out through the venipuncture site *Swollen tissue around the venipuncture site is a manifestation of infiltration due to the IV solution entering the subcutaneous tissue and causing swelling, as the fluid is no longer infusing into the vein
A patient is receiving heparin intravenously. What signs and symptoms would alert you to the patient having adverse effects of heparin? (select all that apply) A. Sleeplessness B. Bleeding gums C. Blood in urine D. Coughing E. Bruising
1. Bleeding gums 2. Blood in urine 3. Bruising *All are signs of bleeding, which is a complication of heparin.
Place the steps in order for the preparation to initiate a blood line: a. Compare patient name, ID number on wrist bank with transfusion record. b. Obtain Y connector setup and saline and prime the filter with saline. c. Clamp off saline and start blood. d. Confirm the presence of a permission slip. e. Obtain baseline vital signs.
1. Confirm the presence of a permission slip. 2. Compare patient name, ID number on wrist bank with transfusion record. 3. Obtain Y connector setup and saline and prime the filter with saline. 4. Obtain baseline vital signs. 5. Clamp off saline and start blood. *All permission slips and then identification must be accomplished prior to starting blood. The blood information is checked with two licensed persons. The filter is primed and the saline is started; vital signs are taken and then the blood is started.
Signs that would cause the nurse to discontinue a blood transfusion would include: (Select all that apply.) a. hives. b. facial flushing. c. nosebleed. d. back pain. e. bloody colored urine.
1. hives. 2. facial flushing 3. back pain. *Symptoms such as hives, facial flushing, back pain, itching, chills, apprehension, and fever are the most common reactions. Many times the primary care provider will order Benadryl for the itching or hives and allow the blood to run.
While checking the patient, the nurse sees that his IV is not running. To troubleshoot, the nurse might (select all that apply) A. lower the container to see if there is a blood return B. discontinue the infusion and restart at a new IV site C. undo the dressing and rotate the needle or cannula D. attempt to aspirate a clot from the IV cannula E. check for kinks in the intravenous tubing
1. lower the container to see if there is a blood return 2. undo the dressing and rotate the needle or cannula 3. attempt to aspirate a clot from the IV cannula 4. check for kinks in the intravenous tubing
The nurse is aware that the disadvantages of infusion pumps include: (Select all that apply.) a. a saline lock is required. b. infusion pump change out every shift. c. the initial expense of machines. d. an alarm that can be deactivated by family. e. the need for special administration sets.
1. the initial expense of machines. 2. an alarm that can be deactivated by family. 3. the need for special administration sets. *Infusion pumps have some disadvantages such as their initial expense, the need for special administration sets, and the fact that the alarm button sounds when the IV container is empty, when there is air in the line, and when there is an occlusion.
The patient's IV is changed to an intermittent intravenous access for antibiotic administration. The nurse goes to hang a prepared piggyback. Place them in correct order A. correctly identify the patient B. flush the cannula with normal saline C. scrub the cannula hub D. set the flow rate for the piggyback infusion E. attach the piggyback tubing to the cannula
1. correctly identify the patient 2. scrub the cannula hub 3. flush the cannula with normal saline 4. attach the piggyback tubing to the cannula 5. set the flow rate for the piggyback infusion
After the blood infusion has started, the nurse should let the blood flow at 2 mL/min for the first ___________ minutes.
15 *The initial rate of blood infusion is 2 mL/min for the first 15 minutes. If the patient tolerates this rate, it can be gradually increased.
A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started? A. 5 minutes B. 15 minutes C. 30 minutes D. 45 minutes
15 minutes *The nurse must remain with the client for the first 15 minutes of a transfusion, which is the most likely time that a tranfusion reaction will occur. This enables the nurse to detect a reaction and intervene quickly. THe nurse engages in safe nursing practice by obtaining coverage for the other clients during this time.
Because of a communication error, the pharmacy says that there is a long delay for a replacement of TPN to be mixed and delivered to the unit for the patient. While awaiting the replacement bag of TPN, the nurse recognizes that a medical order is needed for which type of IV fluid? A. 0.45% Saline B. 5% Dextrose in water C. 10% Dextrose in water D. Lactated Ringer
10% Dextrose in water *If TPN is suddenly discontinued, a patient can experience hypoglycemia. (1) 0.45% saline is a common solution ordered for maintenance replacement of fluids. (2) 5% dextrose is most commonly used as a vehicle for piggyback medications. (4) Lactated Ringer is an isotonic solution that is used for cases of excessive fluid loss, such as trauma or major burns.
A patient who requires an immediate transfusion of blood has previously signed a consent form to receive it. The nurse confirms that the consent was signed within the last: a. 8 hours. b. 12 hours. c. 24 hours. d. 48 to 72 hours.
48 to 72 hours. *A consent to receive blood must be signed by the patient, usually no more than 48 to 72 hours before receiving the blood product.
The nurse is aware that as a safety precaution against over hydration, the tubing drip factor set appropriate for a 6-month-old infant is: a. 60 gtt/mL. b. 20 gtt/mL. c. 15 gtt/mL. d. 10 gtt/mL.
60 gtt/mL. *A microdrip infusion set, which delivers 60 gtt/mL, is used for infants and children.
A patient has an IV of 1000 mL 5% dextrose in 1/2 normal saline (0.45% sodium chloride) infusing via microdrip for 12 hours. The IV is infusing ________ gtt/min.
83 *1000/12 = 83.
The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding? A. An increased hematocrit level B. An increased hemoglobin level C. A decline of the temperature to normal D. A decrease in oozing from puncture sites and gums
A decrease in oozing from puncture sites and gums *Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or the oozing of blood from puncture sites, wounds, and mucous membranes.
A patient who was given intravenous penicillin for a severe infection develops hives, itching, and facial swelling immediately after the infusion. What type of drug reaction is this patient experiencing? a. An adverse reaction b. A paradoxical reaction c. An anaphylactic reaction d. A hypersensitivity reaction
A hypersensitivity reaction *Some drugs (sulfa products, aspirin, and penicillin) can produce allergic (hypersensitivity) reactions that usually occur when an individual has taken the drug and the body has developed antibodies to it.
A patient returns from physical therapy, and her IV has a very sluggish flow, but it was functioning well before going to physical therapy. What is the primary nursing action? A. Call the physical therapist and ask if anything happened to the IV during the treatment session B. Discontinue the IV and restart the IV at a new site C. Assess the IV insertion site and tubing and try repositioning the extremity D. Use a heparin flush to clear the line
Assess the IV insertion site and tubing and try repositioning the extremity *Assess the site and try to troubleshoot; repositioning the extremity is one solution. Also, try to aspirate for a small blood clot. (See Table 36-3 for other troubleshooting tips.) (1) PT should have called you if something happened to the patient that created a potential danger. It is unlikely that you will gain any useful information by calling, but you could if you suspect an unusual circumstance. (2) Discontinue and restart, if you have tried to reestablish flow without success. (4) Use of a heparin flush requires a medical order.
The nurse is preparing an intravenous (IV) solution and tubing for a client who requires IV fluids. While preparing to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse should plan to take which action? A. Change the IV tubing B. Wipe the tubing with Betadine C. Scrub the tubing with an alcohol swab D. Scrub the tubing before attaching it to the IV bag
Change the IV tubing *The nurse should change the IV tubing. The tubing has become contaminated, and, if used, it could result in a systemic infection in the client. Wiping or scrubbing the tubing is insufficient to prevent systemic infection
A patient is receiving IV fluids through an infusion pump. How often should the nurse check the functioning of the pump? a. Every 15 to 30 minutes b. Every 1 to 2 hours c. Every 2 to 4 hours d. Once during the shift
Every 1 to 2 hours *An IV infusion pump should be checked every 1 to 2 hours to ensure that it is functioning properly.
The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the intravenous (IV) of an assigned client who is receiving fluid replacement therapy how frequently? A. Every hour B. Every 2 hours C. Every 3 hours D. Every 4 hours
Every hour *Safe nursing practice includes monitoring an IV infusion at least once every hour for an adult client.
What is the nurse's primary responsibility in the daily care of a patient with a central line? A. Use sterile technique during insertion B. Flush the line according to agency policy C. Verify catheter placement with an x-ray examination D. Rotate the insertion site every 72 hours
Flush the line according to agency policy. *Nurses are responsible for the maintenance of central lines, which would include flushing to ensure patency. (1) Sterile technique is used during the insertion; however, central lines are usually inserted by physicians or advanced practice nurses who have undergone specialized training. (3) The catheter placement should be verified with a radiograph; however, this is the responsibility of the person doing the insertion. The nurse should not use the catheter for infusion until after placement has been verified. (4) The site is not usually changed so frequently. One of the advantages of central line placement over peripheral sites is longevity.
What physical assessment findings would you observe when an IV becomes infiltrated? a. Pallor and pain b. Pallor, warmth c. Pain, warmth, and burning d. Pain, swelling, and redness
Pain, swelling, and redness *Infiltration produces pain, swelling of the area, and redness. Pain with warmth and burning are signs of infection.
The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which? A. Phlebitis of the vein B. Infiltration of the IV line C. Hypersensitivity to the IV solution D. An allergice reaction to the IV catheter material
Phlebitis of the vein *Phlebitis at an IV site results in discomfort and redness, warmth, and swelling proximal to the IV catheter. The IV catheter should be removed, and a new IV should be inserted at a different site.
The nurse evaluating a piggyback IV setup finds an error in the construction of the fluids. Which situation would the nurse correct? a. Secondary bag is hung higher than the primary bag. b. Primary line clamp is closed. c. Slide clamp near the insertion site is open. d. Secondary line clamp is open.
Primary line clamp is closed *When a medication is given via piggyback setup, the secondary bag is hung slightly higher than the primary line and, when the secondary infusion finishes, the primary one takes over again; therefore, all clamps (roller and slide) must be open for the setup to work properly.
The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter while applying pressure to the site with which item? A. Band-Aid B. Alcohol swab C. Betadine swab D. Sterile 2x2 gauze
Sterile 2x2 gauze *A dry, sterile dressing such as sterile 2x2 gauze is used to apply pressure to the site while the cathter is discontinued and removed. This material is absorbent, sterile, and nonirritating to the site. A Band-Aid may be used to cover the site after hemostasis as occurred. An alcohol swab or Betadine would irritate the opened puncture site and would not stop the blood flow
The patient is receiving a blood transfusion and develops a fever, shortness of breath, and a diffuse rash within 10 minutes after the start of the transfusion. What is the priority action? A. Take vital signs and call the primary care provider B. Place the patient in a supine position and start oxygen C. Stop the blood and change the IV tubing D. Slow the blood and check the vital signs
Stop the blood and change the IV tubing. *First stop the blood and change the IV tubing so that the patient does not receive the blood that is within the tubing. (1, 2, 3) Taking the vital signs, starting oxygen, and calling the primary care provider are appropriate actions. The high Fowler position is better initially for oxygenation; if the patient's vital signs suggest shock, the supine position is used. Slowing the blood is not an adequate measure if a transfusion reaction is in progress.
A nurse is adding a secondary piggyback to the patient's existing IV. To use the gravity system, the nurse should hang A. The piggyback bag higher than the maintenance IV bag B. The maintenance IV bag at the same height as the piggyback bag C. The piggyback bag and the maintenance IV bag using Y tubing D. The maintenance IV bag after the piggyback bag is completed
The piggyback bag higher than the maintenance IV bag *If the piggyback bag is higher than the maintenance bag, the fluid from the piggyback will flow in first. As soon as the piggyback is empty, fluid from the maintenance bag will begin. Recall that the fluid level in the piggyback bag must be higher throughout the entire infusion. (2) If the maintenance bag and the piggyback bag are at the same height, the fluid from the maintenance bag can flow up into the piggyback (if there is no backflow valve within the tubing). The bag that has the greater volume will flow first. As the volume of the greater bag depletes, the less the bag will begin to flow. Eventually both would infuse, but the two bags of fluid would be competing for flow. (3) Y-tubing is generally reserved for blood product infusion. It would be an inappropriate waste of a more expensive tubing (which has a special filter). (4) You can manually hang or restart the maintenance IV after the piggyback is completed. In fact, if fluid overload is an issue and you do not have an infusion pump, you may choose to do this; however, this completely eliminates the advantage of having a piggyback setup.
A client who is receiving a blood transfusion pushes the call light for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings? A. Bacteremia B. Fluid overload C. Hypovolemic shock D. Transfusion reaction
Transfusion reaction *The signs and symptoms exhibited by the client are consistent with a transfusion reaction.
The nurse is planning for the initiation of a blood transfusion. The type of tubing the nurse will prepare is a: a. piggyback set. b. primary infusion set. c. controlled volume set. d. Y administration set
Y administration set. *A Y administration set is used to place the blood on one side and normal saline on the other. This is necessary so that the blood can be discontinued but the vein can remain open with the saline in the case of a transfusion reaction or other medically necessary situation.
A patient is receiving total parenteral nutrition (TPN) through a central line. His TPN solution is behind schedule when the nurse comes on duty. The nurse would A. increase the flow rate to "catch up" B. leave the flow rate alone C. notify the primary care provider that the solution is behind schedule D. adjust the flow rate to that which is ordered
adjust the flow rate to that which is ordered