NUR 130 Lab Module 12 EXAM
The nurse is preparing to document insertion of the IV in accordance with the health care provider's orders for normal saline at 100 mL per hour. Which of the following should the nurse include in documentation of the procedure? (Select all that apply.) 1. Number of attempts at insertion. 2. Type of fluid. 3. Location of insertion site. 4. Size and type of catheter or needle. 5. When infusion was begun and at what rate. 6. Expected time to hang next IV bag or bottle. 7. Patient's response. 8. Phlebitis scale rating.
1, 2, 3, 4, 5, 7 The nurse should record in the nurses' notes the number of attempts for insertion, type of fluid, insertion site by vessel, flow rate, size and type of catheter or needle, and when infusion was begun. The patient's response to the procedure may also be included. The expected time to hang the next IV bag or bottle may be reported to the oncoming nursing staff but is unnecessary to include in the nurse's notes. The phlebitis and infiltration scale ratings are unnecessary on a newly inserted IV.
The nurse is informing the patient of actions that may be taken to promote venous distention. Which statement, if made by the patient, indicates further instruction is needed? (Select all that apply.) 1. "I need to keep my arm elevated for 10 to 20 minutes." 2. "You'll come back in a few minutes while I keep this warm towel on my arm." 3. "I've seen other nurse's tap the vein multiple times, maybe that will work." 4. "You can gently stroke the vein to make it pop up."
1, 3 To promote venous distention in the patient, the nurse may place the patient's arm in a dependent position (avoid elevating the arm), and rub or stoke the patient's arm. The nurse may also apply a warm pack to the arm for 10 to 20 minutes. Heat causes vasodilatation. Gentle rubbing or stroking of the patient's arm promotes venous distention. Multiple tapping of the patient's veins should be avoided as it may cause injury to the vein, such as a hematoma, or cause venous constriction.
Which of the following situations indicates peripheral IV access could be discontinued (provided the health care provider has given the corresponding order)? (Select all that apply.) The patient: 1. Who has been receiving IV fluids for fluid maintenance is drinking fluids well and electrolytes are within normal limits. 2. Receives all regularly scheduled medications by mouth and has prn orders for medications administered intravenously. 3. Has completed the course of IV antibiotics and the intravenous access device is unnecessary. 4. Is complaining of pain at the IV site and there is absence of a blood return. 5. Has an arm that is swollen and cool to the touch and complains of pain at the IV site. 6. Is NPO until nausea is resolved. 7. Has an order for normal saline at 125 mL per hour and signs of fluid volume excess are absent. 8. Is being discharged to home on oral (PO) meds.
1, 3, 4, 5, 8 Discontinuing an intravenous infusion is necessary after the prescribed amount of fluid has been infused (i.e., the patient has completed the course of IV antibiotics), when an infiltration occurs (indicated by swelling, pain, pallor, and coolness to the touch at the insertion site), if phlebitis is present (indicated by the presence of redness and pain along the vein pathway), or if the infusion catheter or needle develops a clot at its tip (evidenced by inability to flush the catheter, stopping of the flow). The nurse should make sure the IV catheter is removed before the patient leaves the hospital unless home IV therapy is part of the patient's discharge instructions. If the patient is drinking fluids well and laboratory results indicate electrolytes are within normal limits, an IV infusion for maintenance is unnecessary. The patient's complaints of pain at the IV site and an absence of a blood return may indicate that the catheter lies outside of the vein and should be removed. The patient who is nauseated and NPO requires IV fluids to prevent dehydration. The patient with orders for a continuous IV infusion, without signs of fluid volume excess, should continue to have the infusion as ordered until other indicators suggest otherwise. IV fluids may be unnecessary in a patient with sufficient oral fluid intakes; however, discontinuing peripheral IV access is unwarranted if the patient's prn medication is administered by this route.
The nursing instructor has been observing nursing students initiate an IV infusion. Which action(s), if made by the nursing student, indicate(s) that further instruction is needed? (Select all that apply.) The nursing student: 1. Performs hand hygiene, spikes the bag of fluids, primes the tubing removing all air bubbles, replaces the cap on the end of the tubing, applies the tourniquet and identifies an accessible vein, removes the tourniquet, applies gloves, and cleans the site in preparation for venipuncture. 2. Cleans the insertion site with chlorhexidine solution in a back-and-forth motion for 30 seconds; allows the area to dry; then, while wearing gloves, palpates the vein before inserting the catheter at a 10- to 30-degree angle. 3. Applies the tourniquet, cleans the site, allows it to dry, performs the venipuncture, looks for blood return, advances the catheter off the stylet, applies pressure above the insertion site, connects the tubing, starts the infusion, and releases the tourniquet. 4. Removes gloves to tape and apply the transparent dressing over the intravenous site. Tapes tubing to transparent dressing.
2, 3, 4 The nursing student should not palpate the prepared site before venipuncture. The nursing student should release the tourniquet right after applying pressure and before connecting the tubing. The student should keep the gloves on until the end of the procedure, after discarding used needles and supplies, when the danger of contact with body fluids is decreased. The nursing student performed the sequence correctly when preparing the IV fluids for infusion and selecting and cleansing the site in preparation for venipuncture. Additional tape should not be placed on transparent dressing. Tubing should be secured next to dressing.
A 4-year-old child was recently admitted to the hospital and has orders for an intravenous (IV) line to be started. Which of the following is an acceptable IV insertion site for a child? 1. The scalp. 2. The antecubital space. 3. Ventral surface of the wrist. 4. The forearm.
4 The forearm is an acceptable site for a child. The scalp is used with infants. The antecubital space is avoided because the antecubital fossa is used for blood draws, and placement in this area limits mobility. The dorsal surface of the hand in the older adult is avoided because these patients have fragile veins, and this site may be easily bumped. Venipuncture in ventral surface of wrist is painful and has potential for nerve damage.
The student nurse is preparing to initiate an IV on a 36-year-old patient who is to receive an IV infusion for fluid maintenance. At this time, surgery is unanticipated. Which size catheter should the nursing student select? a. 18-gauge. b. Butterfly needle. c. 22-gauge. d. 24- or 26-gauge. e. A variety of sizes because the weight of the patient is unknown.
c A 22-gauge catheter is appropriate for an adult requiring fluid maintenance. An 18-gauge catheter would be appropriate for an adult patient scheduled for surgery or who may anticipate receiving blood products or require a rapid rate of infusion of fluids. A 24- or 26-gauge catheter may be appropriate for an older adult requiring IV medications or fluids. A butterfly needle is appropriate for an infant requiring IV fluids. The patient's age and purpose of IV insertion is significant when determining gauge of catheter to select.
Which of the following IV solutions would be infused for the patient who has been vomiting and is requiring fluid replacement? a. 0.9% sodium chloride b. 0.45% sodium chloride c. D5LR d. D5NS
a An isotonic solution, such as 0.9% normal saline, 5% dextrose in water (D5W), or lactated Ringer's (LR) is used most often to replace extracellular volume (e.g., prolonged vomiting). A hypotonic solution, such as 0.45% sodium chloride, may be used with a patient experiencing a hypertonic fluid imbalance such as with hyperosmolar hyperglycemia. The hypotonic solution will dilute the extracellular fluid and rehydrate the cells. D5LR is a hypertonic solution and may be used to pull fluid into the vascular space. D5NS is a hypertonic solution and may be used to pull fluid into the vascular space.
The nurse is performing a routine physical assessment on a patient with heart failure. The nurse finds the following data: Patient is alert and oriented, face flushed, lung sounds with rhonchi, respirations slightly labored at a rate of 28, heart rate 98, blood pressure 140 over 92, abdomen soft with bowel sounds present, clear yellow urine in bedside drainage bag of Foley catheter, and +2 edema of lower extremities. The patient has an IV of normal saline infusing at 125 mL per hour in the left forearm without redness at the IV site. The patient denies any complaints of pain. The nurse discontinues the IV, notifies the health care provider, raises the head of the bed, and monitors the patient's vital signs. Which of these nursing actions is wrong? a. Discontinuing the IV. b. Notifying the health care provider. c. Raising the head of the bed. d. Monitoring the patient's vital signs.
a The patient is demonstrating signs and symptoms of fluid volume excess (FVE). The nurse should slow the rate of the IV, notify the health care provider, raise the head of the bed to facilitate breathing, and continue to monitor the patient's vital signs. The nurse should avoid discontinuing the IV unlesa s health care provider's orders are received to do so.
Nurses must be astute in their assessment skills to identify intravenous infusion problems to prevent complications. Match the IV infusion problem to the assessment findings. a. Bleeding b. Occlusion c. Infection d. Infiltration e. Fluid volume excess f. Phlebitis 1. Swelling, pain,redness, warmth, and palpable venous cord at insertion site 2. Swelling, pain, pallor, and coolness at insertion site 3. Saturated dressing 4. Elevated temperature, purulent drainage at insertion site, pain 5. Slowed or stopped infusion with roller clamp open 6. Shortness of breath, crackles in the lungs, tachycardia
a, 3 b, 5 c, 4 d, 2 e, 6 f, 1 An elevated temperature, chills, malaise, purulent drainage at the insertion site, and pain are symptomatic of infection. Shortness of breath, crackles on auscultation of the lungs, edema, and tachycardia indicate fluid volume excess. An infusion that has slowed or stopped with the roller clamp open indicates an occlusion. Swelling, pain, pallor, and coolness at the IV insertion site are indicative of infiltration. Phlebitis is indicated by pain, erythema, and warmth at the IV site. Bleeding is manifested as blood at the insertion site or a saturated dressing.
Nurses take certain actions when troubleshooting intravenous infusions. Match the intravenous infusion problem to the corrective nursing action. a. Check for kinks in tubing, restrictive dressing, or patient lying on tubing; this may require site relocation b. Discontinue IV; insert new line in another extremity; elevate the extremity; wrap in warm, moist towel for 20 minutes. c. Apply a pressure dressing over the site. d. Discontinue IV, retain previous catheter for possible culture, notify health care provider. e. Slow the rate of infusion, notify the health care provider, raise the head of the bed, monitor vital signs. f. Determine cause; may need to remove IV catheter and restart elsewhere, apply heat and elevate arm 1. Infiltration 2. Phlebitis 3. Infection 4. Fluid volume excess 5. Occlusion 6. Bleeding
a, 5 b, 1 c, 6 d, 3 e, 4 f, 2 In the event of phlebitis, the nurse should determine the cause, apply heat and elevate the limb. If there is bleeding at the IV site, the nurse may apply a pressure dressing over the site. If fluid volume excess is manifested, the nurse should slow the rate of infusion and notify the health care provider. The nurse may elevate the head of the patient's bed to promote oxygenation and continue to monitor vital signs. In the occurrence of infiltration, the nurse should discontinue the IV and insert a new line in another extremity. The nurse may elevate the extremity to promote venous return and wrap the extremity in a warm, moist towel for 20 minutes to promote circulation and comfort. If there is evidence of infection at the IV site, the IV should be discontinued and the health care provider notified. The nurse should retain the catheter for possible culture if ordered by the health care provider. If occlusion is suspected, the nurse should first check for kinks in the tubing or if the patient is lying on the tubing. The nurse may also check the dressing to make sure blood flow is unimpeded. The nurse may assess for a blood return by lowering the bag of IV fluids below the level of the insertion site or by aspiration. The nurse should avoid forcefully flushing an intravenous catheter because it could cause the catheter tip to break, creating a possible embolus. If an occlusion is caused by clot formation, the IV will require relocation. Having the patient open and close his or her fist aids in promoting venous distention for IV insertion.
Which of the following actions fail to follow practices of infection control, therefore placing either the nurse or patient at risk? (Select all that apply.) a. Unable to obtain a flashback of blood, the nurse withdraws the catheter and needle and reinserts it at a deeper angle. b. The nurse uses a needle when aspirating for a blood return to assess for patency. c. The nurse replaces the peripheral venous catheter and rotates the site every 96 hours or immediately when complications appear. d. The nurse does not palpate the insertion site after the skin has been cleansed.
a, b The nurse should obtain a new catheter when attempting IV insertion a second time. The nurse should use the needleless system whenever possible to prevent an accidental needle stick. According to the Infusion Nurses Society, the site should be rotated based on clinical assessment indicating signs or symptoms of IV-related complications or at least every 96 hours. To avoid contaminating the clean insertion site, the nurse should refrain from touching the insertion site, even with a clean glove.
A trauma patient is received in the emergency room. Which size catheter should the nurse select to initiate the IV? a. 22-gauge. b. 18-gauge. c. 22- to 24-gauge. d. Butterfly needle
b A trauma patient may require rapid infusion of fluids or blood or blood products and should receive an 18-gauge catheter. A 22-gauge catheter is appropriate for IV fluids in an adult. A 22- to 24-gauge catheter is appropriate for an older adult or child. A butterfly needle is used with infants.
Upon discontinuing peripheral intravenous access, the nurse notes the catheter tip is missing. What action should the nurse take? a. Cover the site with a pressure dressing. b. Notify the health care provider immediately. c. Apply ice to the insertion site. d. Apply a warm compress to the extremity.
b If the catheter tip is missing, the health care provider should be notified immediately because the broken tip can cause an embolus and an emergency situation. Applying a pressure bandage or ice is appropriate action to slow bleeding with a hematoma. A warm, compress would be applied to relieve phlebitis.
In which of the following situations would it be acceptable to allow the IV infusion (IV access) to continue? a. swelling above the insertion site and cool temperature. b. Redness, tenderness, and warmth and palpable cord at IV site. c. IV is infusing but at a slower rate than ordered. d. IV fluid container empties with subsequent loss of IV line patency.
c The nurse should check for positional change that may affect the rate, as well as the height of the IV container or kinking of tubing. Once the cause of the slower infusion rate is identified and appropriate interventions take place, the IV infusion may continue. Swelling and cool skin temperature indicate infiltration. The IV should be discontinued and restarted in another location. Swelling above the insertion site and cool temperature indicate vein inflammation or phlebitis. Clotting of the catheter can cause loss of patency. The IV should be discontinued and restarted in a new location.
A 4-year-old child was recently admitted to the hospital with orders for an IV to be started. The nurse prepares the IV infusion and primes the tubing, applies a tourniquet, selects a vein in the antecubital space, releases the tourniquet, applies gloves and cleans the site with chlorhexidine, reapplies the tourniquet, performs the venipuncture, obtains a blood return, advances the 24-gauge catheter off the stylet, applies pressure above the insertion site, releases the tourniquet, connects the tubing, and begins the infusion. The nurse then secures the catheter with tape and a dressing, adjusts the flow rate, and labels the dressing. Which action made by the nurse was incorrect? a. The nurse was correct in all actions. b. Use of a tourniquet. c. Site selection. d. Timing of beginning the infusion. e. Use of a 24-gauge catheter. f. Use of chlorhexidine to cleanse the site.
c The nurse was incorrect in site selection. The foot and the forearm are acceptable sites for a child. Areas of flexion such as wrist or antecubital area should be avoided because there is an increased risk for infiltration, phlebitis, or dislodgement. A tourniquet may be used with a child. A rubber band may be used with an infant and a blood pressure cuff with an elderly person. Timing of initiating the infusion was correct. Once a blood return is obtained, the tourniquet is released, and the tubing is properly connected, the nurse should begin infusing the IV fluids to prevent clotting of the catheter. A 22- to 24-gauge catheter is used for children. Chlorhexidine is the antiseptic cleansing agent of choice.
A 48-year-old man has to have his IV restarted. It is currently located in his left lower forearm. He has a history of renal failure and has a shunt located in his right arm for dialysis. Which of the following is an appropriate site for IV relocation? a. The right hand. b. Distal to the previous IV site on the left arm. c. Either foot. d. The left arm, proximal to the previous IV site. e. The left hand where there is a prominent hardened cordlike vein. f. The dorsal left wrist where the veins bifurcate. g. The right arm.
d The acceptable site for relocating this patient's IV is proximal to the previous IV site of the left arm. The right upper extremity should be avoided because of the presence of the vascular (dialysis) shunt. Any time an extremity has compromised circulation such as with a dialysis shunt, mastectomy, or paralysis, the area should be avoided because these venous alterations can increase the risk of complications. Sites distal to previous venipuncture sites, sclerosed or hardened cordlike veins, and areas of venous valves or bifurcation should also be avoided. The foot is common with children but is avoided in the adult because of the danger of thrombophlebitis.
The nurse is preparing the IV for infusion. The nurse has checked the IV solution using the six rights of medication administration. The nurse checked the solution for clarity and expiration date. Which of the following steps, if performed by the nurse, require correction? a. The nurse opens the infusion set and moves the roller clamp 1 to 2 inches below the drip chamber and moves it to the "off" position. b. The nurse removes the protective sheath over the IV tubing port on the IV bag and on the insertion spike of the tubing. c. Without touching the spike, the nurse inserts it into the tubing port of the IV and primes the infusion tubing with IV solution. d.The nurse checks the length of tubing and the drip chamber to make sure that both are filled with fluid and that no air is remaining.
d The drip chamber should only be filled 1/3 to 1/2 full to be able to see the drops and determine that it is running at the appropriate rate. The other actions were performed correctly
Which of the following would be an appropriate site for placement of an IV? a. The arm on the same side of a mastectomy. b. The flaccid arm of a patient who previously experienced a cerebrovascular accident (stroke). c. Distal to the previous site as long as the vein does not appear red. d. The patient's nondominant forearm.
d The patient's nondominant forearm is preferred because an IV placed there is less likely to inhibit mobility and activities of daily living. Place the IV at the most distal site when possible. Using a distal site first allows for the use of proximal sites later if the patient would need a venipuncture site change. Avoid areas affected by pain, infections, wounds, cerebrovascular accident, paralysis, or mastectomy.