Mosby - IV - Administering IV Fluid Therapy

Gauze dressings that cover a catheter site must be changed every _______. Intravenous tubing administration sets can remain sterile for _____.

48 hours 96 hours

Which action will best minimize the patient's risk for vein injury when removing an IV access device from a patient's arm? a.) Keep the hub parallel to the skin. b.) Cleanse the site with an antibacterial swab. c.) Cut the dressing to facilitate its removal. d.) Turn the IV tubing roller clamp to the "off" position.

a.) * Keep the hub parallel to the skin.* CORRECT. Keeping the hub parallel to the skin minimizes vein trauma during removal of the device.

What might the nurse do to minimize the risk for injury in a patient receiving IV therapy? a.) Regulate the flow rate of the infusion. b.) Assess the patient frequently for pain at the IV site. c.) Monitor the IV site frequently for signs of infiltration and phlebitis. d.) Educate the patient regarding symptoms of infiltration and phlebitis.

a.) * Regulate the flow rate of the infusion.* CORRECT. Regulating the rate will minimize the risk for fluid overload.

The nurse observes erythema at the insertion site of a patient's IV infusion device. When asked, the patient denies pain at the site. Using the phlebitis scale, what score does the nurse give the injury? a.) 1 b.) 2 c.) 3 d.) 4

a.) *1* CORRECT. The nurse would give this injury a score of 1, which indicates redness at the access site with or without pain.

Which action would the nurse perform to best ensure effective insertion of a venous access device into a patient's arm? a.) Anchor the vein by placing a thumb 1 to 2 inches below the site. b.) Insert the device tip at a 45-degree angle distal to the proposed site. c.) Place the patient's left arm in a dependent position for 5 minutes before assessment. d.) Apply a tourniquet to the left antecubital fossa 8 to 12 inches above the proposed site.

a.) *Anchor the vein by placing a thumb 1 to 2 inches below the site.* CORRECT. This action stabilizes the vein, increasing the possibility of a successful insertion.

When preparing to insert a venous access device, how can the nurse encourage patient compliance with the procedure? a.) Assess the patient's understanding of the placement of the device. b.) Insert the access device as quickly as possible. c.) Ask the patient to select the arm preferred for access. d.) Apply a topical anesthetic to the area before inserting the device.

a.) *Assess the patient's understanding of the placement of the device.* CORRECT. The nurse would assess the patient's understanding of device placement before inserting the device. Doing so would increase patient compliance with the procedure.

The nursing assistive personnel (NAP) reports to the nurse that a patient's intravenous access device dressing is wet. What would the nurse do first? a.) Assess the site. b.) Instruct the NAP on how to change the dressing. c.) Remove the device, and insert a new one. d.) Reinforce the dressing with more gauze.

a.) *Assess the site.* CORRECT. The nurse would first assess the site to check for infiltration and to see if the IV has become dislodged.

Which action will the nurse take to minimize a patient's risk for injury when applying a gauze dressing to an infusion site? a.) Avoid encircling the arm with tape b.) Not secure the tubing and catheter hub with tape c.) Secure the tubing in two different locations on the arm d.) Label the dressing with the date and time of application

a.) *Avoid encircling the arm with tape* CORRECT. The nurse will avoid encircling the arm with tape, because doing so can impede circulation in the arm.

What might the nurse do to improve a patient's cooperation during the removal of an IV access device? a.) Describe the entire procedure to the patient. b.) Assure the patient that you will remove the IV catheter quickly. c.) Assure the patient that the procedure will take only about 5 minutes. d.) Tell the patient that the procedure will cause only a slight burning sensation.

a.) *Describe the entire procedure to the patient.* CORRECT. Describing the entire procedure in advance will minimize fear and thus encourage the patient's cooperation.

How might the nurse prepare a patient to anticipate some discomfort when inserting a venous access device? a.) Instruct the patient to expect a sharp, quick stick. b.) Insert the access device as quickly as possible. c.) Apply a topical anesthetic to the area before inserting the device. d.) Promise that the procedure will not hurt once the device has been inserted.

a.) *Instruct the patient to expect a sharp, quick stick.* CORRECT. Educating the patient to have reasonable expectations about the possible discomfort will best prepare him or her for it.

The nurse consistently observes that the positioning of a confused patient's arm has a direct effect on the flow rate of the intravenous (IV) solution. What might the nurse do to ensure infusion of the patient's IV fluid at a consistent rate? a.) Restart the IV in another location less affected by the patient's positioning. b.) Include this information in the shift report regarding this patient. c.) Assess the flow rate every 1 to 2 hours. d.) Instruct the patient to avoid positioning the arm in ways that alter the flow rate of the solution.

a.) *Restart the IV in another location less affected by the patient's positioning.* CORRECT. Restarting the IV in another location is the best option to ensure the effectiveness of the patient's IV therapy.

Which action will the nurse take to minimize a patient's risk for injury when applying a dressing to an infusion site? a.) Use aseptic technique throughout the process. b.) Apply a skin protectant to the skin before the intervention. c.) Apply a transparent dressing that allows for visualization of the site. d.) Explain the process to the patient before implementation.

a.) *Use aseptic technique throughout the process.* CORRECT. Following aseptic technique throughout the dressing application will minimize the patient's risk for injury related to infection.

What would the nurse do to assess a patient's risk for embolus when removing a venous access device? a.) Inspect the site for redness. b.) Visualize the tip of the IV device. c.) Palpate the site for possible edema. d.) Ask the patient to rate any pain at the site.

b.) * Visualize the tip of the IV device.* CORRECT. Damage to the tip of the device, resulting in a portion of the device remaining in the vessel, may cause an embolus to form.

A patient's IV site has developed phlebitis scored as a 4 on the phlebitis scale. What would the nurse do to help treat the site? a.) Apply a cool compress. b.) Apply a warm compress. c.) Apply a pressure dressing. d.) Apply an elastic compression wrap.

b.) *Apply a warm compress.* CORRECT. An IV site with evidence of phlebitis is to be wrapped with a warm compress.

Which instruction might the nurse give to nursing assistive personnel (NAP) when caring for a patient whose IV access device is to be removed? a.) "Remember to wear gloves to minimize the risk for infection." b.) "Be sure to keep pressure on the site for at least 2 to 3 minutes." c.) "Let me know if you notice any bleeding on the site dressing." d.) "Make sure the patient knows to notify me if the IV site becomes painful."

c.) * "Let me know if you notice any bleeding on the site dressing."* CORRECT. The nurse might offer this instruction because the task of reporting signs of bleeding may be delegated to NAP.

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a venous access device? a.) "Assess the IV site frequently for signs of inflammation." b.) "Be sure not to obscure the insertion site with the dressing." c.) "Let me know if you notice that the dressing has become damp." d.) "Make sure the patient knows to notify me if the IV site becomes painful, swollen, or red."

c.) * "Let me know if you notice that the dressing has become damp."* CORRECT. The task of reporting if a dressing becomes damp may be delegated to NAP.

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with an intravenous access device? a.) "Assess the IV site frequently for signs of inflammation." b.) "Be sure not to obscure the insertion site with the dressing." c.) "Let me know when you notice that the IV bag contains less than 100 milliliters." d.) "Explain the symptoms of infection to the patient."

c.) * "Let me know when you notice that the IV bag contains less than 100 milliliters."* CORRECT. The task of reporting when the level of fluid in the IV bag is low may be delegated to NAP.

When applying a dressing to an infusion site on a patient's left forearm, what will the nurse do to ensure proper maintenance of the tubing? a.) Apply a transparent dressing to the insertion site. b.) Use a catheter stabilizing device when applying the dressing. c.) Apply the dressing proximal to the tubing and catheter hub connector. d.) Secure the tubing to the patient's dressing with 1-inch tape.

c.) * Apply the dressing proximal to the tubing and catheter hub connector.* CORRECT. Applying the dressing proximal to the tubing and catheter hub connector will allow the tubing to be disconnected and changed when indicated.

Which action minimizes the patient's risk for injury when inserting a venous access device into the arm? a.) Wearing clean gloves during the procedure b.) Using a larger vein found on the palmar (ventral) side of the wrist c.) Checking for a radial pulse once the tourniquet has been applied d.) Priming the extension tubing after attaching it to the newly placed venous access device

c.) *Checking for a radial pulse once the tourniquet has been applied* CORRECT. Assessing for a radial pulse after the tourniquet is in place ensures that circulation to the distal extremity has not been compromised.

Why is it important to label the gauze dressing covering the site of an intravenous access device with the date, time, and nurse's initials? a.) Reminds the nurse to document the insertion of the device b.) Proves that the access site was assessed c.) Informs the nurse and other staff when the next dressing change is due d.) Reminds the nurse when to change the infusion tubing

c.) *Informs the nurse and other staff when the next dressing change is due* CORRECT. The gauze dressing over an intravenous access site must be changed every 48 hours. This is the reason for labeling the dressing with the date, time, and nurse's initials.

The nurse is inserting an over-the-needle catheter into a newly admitted patient. What will the nurse do after confirming blood return? a.) Loosen or remove the tourniquet. b.) Advance the catheter 1 inch into the vein. c.) Lower the catheter until it is flush with the skin. d.) Thread the catheter into the vein up to the hub.

c.) *Lower the catheter until it is flush with the skin.* CORRECT. Lowering the catheter until it is flush with the skin minimizes the risk of passing the needle through the opposite vessel wall.

The nurse is preparing to insert a venous access device into a newly admitted 75-year-old patient. Which vein is not an appropriate choice for IV insertion in this patient? a.) Basilic vein b.) Cephalic vein c.) Superficial dorsal vein d.) Median cubital vein

c.) *Superficial dorsal vein* CORRECT. Superficial veins located on the dorsal surface of the hand must be avoided because of the risk for infiltration due to excessive movement. They are also more fragile in older adults.

Which of the following technique(s) is/are best for minimizing a patient's risk for injury when inserting a venous access device? a.) Inserting the needle with the bevel up b.) Using a vein on the dorsal surface of the arm c.) Holding the skin taut directly below the site d.) All of the above

d.) *All of the above* CORRECT. All of these actions will minimize injury to the patient.

Which technique is most accurate in identifying an appropriate vein site for IV catheter insertion into the arm? a.)Remove any clothing that is covering the arm. b.)Apply a warm washcloth to the arm at the proposed site. c.) Elevate the selected arm on a pillow for 2 to 3 minutes. d.) Apply a tourniquet to the selected arm 4 to 6 inches above the proposed site.

d.) *Apply a tourniquet to the selected arm 4 to 6 inches above the proposed site.* CORRECT. Applying a tourniquet will distend the vein, making the intended insertion point more visible and allowing the nurse to determine if the vein can accommodate the IV catheter.

What will the nurse do to prevent possible complications after removing an IV access device in a patient on anticoagulant therapy? a.) Instruct the patient to report immediately any sign of bleeding on the site dressing. b.) Perform hand hygiene and wear clean gloves while removing the device. c.) Encourage the patient to keep a cold compress on the site for 15 minutes. c.) Apply firm pressure to the site with sterile gauze for 10 minutes.

d.) *Apply firm pressure to the site with sterile gauze for 10 minutes.* CORRECT. Applying firm pressure will facilitate clotting. Maintaining pressure at the site for 5 to 10 minutes is recommended because the patient is receiving medication that prolongs the amount of time it takes for blood to clot.

The nurse is using chlorhexidine to prepare the site before inserting a venous access device into the median cubital vein of a 60-year-old patient. Which action is correct? a.) Wash the site with soap and water. b.) Allow the site to dry 1 to 2 minutes after cleansing it with chlorhexidine. c.) Cleanse the site using a circular motion, starting at the insertion site and working outward. d.) Cleanse the area by first swabbing horizontally, then vertically with the applicator for about 30 seconds.

d.) *Cleanse the area by first swabbing horizontally, then vertically with the applicator for about 30 seconds.* CORRECT. Chlorhexidine thoroughly cleanses the skin when first horizontal and then vertical swabbing is performed for 30 seconds.

A single nurse should not make more than ______ at initiating IV access. After ____ attempts, the nurse should have another nurse attempt the insertion.

two attempts