skills lab 4 questions

Which action would the nurse perform to best ensure effective insertion of a venous access device into a patient's arm?

Anchor the vein by placing a thumb 1 to 2 inches below the site.

After drawing blood from a patient's central venous access device (CVAD), what would the nurse do to ensure that the device resumes proper functioning?

Flushing the catheter with preservative-free 0.9% sodium chloride minimizes the risk of clot formation at the catheter tip and ensures continued proper functioning of the device.

Which nursing intervention is most important in ensuring safe infusion of a medication delivered by IV piggyback through a saline lock?

Flushing the saline lock with 0.9% sodium chloride solution to assess for placement and patency before initiating a piggyback infusion reduces the likelihood of infiltration and extravasation.

why does the nurse elevate the head of the bed 30° for pt receiving an intermittent tube feeding?

reduces risk for aspiration

A patient has a blood transfusion reaction, and the transfusion is stopped. What should the nurse do with the remaining blood and transfusion administration set?

return both to blood blank

A patient receiving a unit of blood complains of feeling cold and begins to have shaking chills. What is the nurse's first action

stop the transfusion

tube feeding & checking GVR

--check gastric residual volume (GVR) every 4-6 hrs --draw 10-30 ml of air into syringe then connect to end of tube & inject the air. then pull back to obtain GVR --check pH & volume --*do NOT administer tube feeding if single GVR > 500 ml or if two consecutive GVRs taken 1 hour apart are each >250 ml* --flush tubing w/ 30 ml water --let bag empty over 30-45 minutes --flush tube before & after feeding --new admin. set every 24 hours

What is the most important nursing intervention to ensure the patient's safety when initiating infusion of an analgesic by mini-infusion pump?

Staying with the patient during the first few minutes of the infusion

A patient's central parenteral nutrition (CPN) order has been changed to a different solution, and the present solution is to be discontinued immediately. What should the nurse do until the new solution is delivered by the pharmacy?

If CPN must be discontinued suddenly, a solution of 10% dextrose in water can be given at the same infusion rate in order to prevent hypoglycemia.

What would the nurse do if he or she encountered resistance when inserting a nasogastric tube?

If the patient starts to cough, experiences a drop in oxygen saturation, or shows other signs of respiratory distress, withdraw the tube into the posterior nasopharynx until normal breathing resumes. Do not force the tube or push it against resistance.

Which nursing action is appropriate when feeding gastric residual is 50 mL?

If the volume of the residual stomach contents is less than 250 mL, it can be returned to the stomach via the feeding tube.

Which technique(s) is/are best for minimizing a patient's risk for injury when inserting a venous access device?

Inserting the needle with the bevel up; using a vein on the dorsal surface of the arm; and holding the skin taut directly below the site

What is the most important action the nurse can take to protect the patient when administering a narcotic analgesic by IV bolus? A) Injecting the medication at the prescribed rate B) Observing the insertion site after giving the medication C) Instructing the patient about side effects to report to the nurse D) Using an alcohol swab to wipe the insertion port on the primary tubing

A

What might the nurse do to reduce the patient's discomfort before inserting a nasogastric tube? A) Examine each naris for patency and skin breakdown. B) Place the patient in the high-Fowler's position. C) Anesthetize the throat. D) Have the patient take a few sips of water.

A

Which patient does not have a medical condition that contraindicates placement of a nasogastric tube? A) A 28-year-old patient who fractured a femur after heavy drinking B) A 73-year-old patient who is on anticoagulation therapy. C) A 54-year-old patient who broke a cheekbone in a fall D) A 67-year-old patient with a history of unexplained nosebleeds

A

While palpating the skin around a patient's CVAD insertion site, the nurse elicits a crackling sound. What might this finding indicate?

A crackling sound or sensation probably indicates subcutaneous emphysema as a manifestation of pneumothorax, hemothorax, air embolism, or hydrothorax.

What will the nurse need before removing a patient's nasogastric tube?

A health care provider's order

When preparing to infuse a bag of parenteral nutrition through a patient's central line, the nurse notices that the solution has coalesced. What is his or her best response?

A solution that has coalesced cannot be used. A replacement must be requested from the pharmacy.

Which action will best minimize the patient's risk for vein injury when removing an IV access device from a patient's arm?

Keeping the hub parallel to the skin minimizes vein trauma during removal of the device.

Why does the nurse kink the nasogastric tube before removing it from a patient?

Kinking the tube keeps any residual fluid in the tube from flowing out.

What is the best way to prevent infection and conserve resources when terminating an IV piggyback medication infusion in a patient who also has a primary fluid infusion?

Leave both the piggyback tubing and the bag attached to the primary line Y-site port until the next scheduled dose. (this will help maintain tube sterility while conserving supplies and nursing time.)

When caring for a patient who has a CVAD, which sign may indicate infection at the insertion site?

Patient's oral temperature gradually increases

Which action would the nurse perform to ensure patient safety during PPN and fat emulsion therapy?

Allow a refrigerated fat emulsion to sit at room temperature for 1 hour before infusing it.

Which nursing action is most important to ensure patient safety when infusing a fat emulsion?

Assess the patient every 10 minutes for 30 minutes after starting the infusion.

If the nurse does not see blood return when aspirating the saline lock in preparation for an IV bolus medication, what is the next step?

Assess the site for swelling or coolness while flushing the saline lock with normal saline: Blood return may be absent with a smaller-gauge catheter. Infusing normal saline while checking for infiltration ensures that the catheter tip is both patent and in the vein. finding a new IV site may not be necessary

What is the best way to protect a patient from an IV site injury when giving an antibiotic medication by piggyback?

Assessing IV site placement and patency before initiating an IV medication is important in preventing IV infiltration.

A patient is prescribed to receive an infusion of 20% fat emulsion. The nurse informs the patient that this infusion will last how long?

At least 8 hours

Which patient safety issue is specific to administration of medication by IV bolus?

Determining that the medication is compatible with the IV solution

Which action by the nurse helps to ensure patient safety when administering IV fluids by gravity to very young children?

Using a volume-control device for a gravity infusion enhances patient safety by preventing an accidental fluid bolus that causes circulatory overload.

Which step to protect the patient from infection is of special concern when preparing a mini-infusion pump to deliver an analgesic?

Using an antiseptic swab on the insertion port minimizes the patient's risk for infection.

Which nursing action will best ensure the safety of a patient who is about to receive an infusion of parenteral nutrition?

Verify the physician's order for central parenteral nutrition (CPN) and the flow rate.

What would the nurse do to assess a patient's risk for embolus when removing a venous access device?

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

Which action by the nurse would reduce his or her exposure to blood borne pathogens while administering fluids to a patient by mini-infusion pump?

applying clean gloves

a nurse flushing a capped, peripheral venous access device finds that the IV does not flush easily. what is the most appropriate intervention in this situation?

aspirate and attempt to flush the line again

when preparing to administer a med by IV bolus through an intermittent IV (INT) device, it is vital that the nurse do which of the following actions first?

assess the IV site for redness, swelling, or discomfort

which instruction might the nurse give to a CNA regarding the care of a patient with an IV in place?

"let me know if you notice the IV fluid in the IV bag is getting low (less than 100 ml left)"

What is the initial infusion rate for a 20% fat emulsion?

1 mL/min for first 15-30 min

how often should you change IV transparent dressings? what about gauze dressings?

transparent: every 5-7 days & prn gauze: every 48 hours & prn

What would minimize the nurse's risk for contamination during the removal of a nasogastric tube?

wearing treatment gloves

when a nurse attempts to pass a nasogastric tube through the patient's pharynx, the patient begins to cough & gag, and the nurse hears air escaping from the tubing. which would be the most appropriate intervention in this situation?

withdraw the tube slightly and instruct pt to breathe easily & take sips of water while you continue to advance the tube

drawing blood

--if you're drawing blood from a pt w/ infusion *turn off infusion for at least 1 minute before* --otherwise, obtain sample from a *peripheral vein*. if multi-lumen catheter is in place, draw from *distal lumen* (usually the largest) --clean site/port --aspirate to see blood then flush w/ 3-5 ml saline --w/d *4-5 ml blood for discard sample* --attach vacutainer to end of hub, unclamp cathether & w/d blood specimen w/ appropriate specimen tube --reclamp and remove, --clean hub again --flush w/saline --if required, flush w/ heparin --new gloves to replace injection cap

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?

1

An adult patient is prescribed to receive a unit of packed red blood cells. Which size intravenous catheter does the patient need to safely receive this blood? 30-gauge 25-gauge 18-gauge 10-gauge

18-gauge: Blood should be administered to an adult using a 14- to 24-gauge short peripheral catheter.

A patient is to receive one unit of packed red blood cells over 2 hours. Which rate is the usual flow rate for the first 15 minutes of a blood transfusion?

2 ml/min

A patient received two 300-mL units of packed red blood cells, and the line was flushed with 25 mL of solution between the units. What is the total amount of fluid the nurse will document having provided to the patient?

625 ml

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) Regulating the rate will minimize the risk for fluid overload.

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

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

What will the nurse do to prevent possible complications after removing an IV access device in a patient on anticoagulant therapy?

Apply firm pressure to the site with sterile gauze for 10 minutes: 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 preparing equipment to administer a unit of blood to a patient. Which type of fluid would the nurse piggyback with the blood transfusion?

Blood and blood products can be administered only with 0.9% normal saline. No other solution is to be administered or piggybacked with blood or blood products.

What would the nurse do if he or she were not able to insert a nasogastric tube in either of a patient's nares? A) Ask another nurse to attempt the insertion. B) Document the attempts in the patient's medical record. C)Notify the physician that the attempts were unsuccessful. D) Allow the patient to rest for 30 minutes before resuming the process.

C

Which information is not necessary for the nurse to include when documenting the use of an electronic infusion device (EID) for an intravenous infusion? A) Location of the insertion site B) Time at which the infusion began C) Patient's pulse and heart rate D) Hourly volume flow rate of the infusion

C

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) 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) Assessing for a radial pulse after the tourniquet is in place ensures that circulation to the distal extremity has not been compromised.

Which action will best minimize a patient's risk for infection while receiving central parenteral nutrition (CPN)?

Change the CPN infusion tubing at least once every 24 hours.

What is the most important way in which the nurse can reduce the risk for infection in a patient with a CVAD that has a gauze dressing?

Change the dressing every 48 hours.

What can the nurse do to help protect the patient from infiltration of IV medication?

Check the IV site for placement before and after the infusion.

How would the nurse assess a patient's central venous access device (CVAD) for damage or breakage?

Check the catheter for pinholes and tears.

How could the nurse assess the patency of a nasogastric (NG) tube being used for enteral nutrition?

Check the gastric residual volume.

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?

Cleanse the area by first swabbing horizontally, then vertically with the applicator for about 30 seconds.

After drawing blood from a central venous access device (CVAD), which action would minimize the patient's risk for infection when reconnecting prescribed intravenous fluids?

Cleansing the IV needleless connector and the end of the IV tubing with a 2% chlorhexidine swab

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) 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.

Which action can the nurse take to ensure a quality blood sample when drawing blood from a patient's central venous access device (CVAD) site?

Discard the first 4 to 5 mL of blood drawn.--Discarding the first sample reduces the risk of drug concentrations or a diluted specimen.

Which action would the nurse take if an intravenous (IV) insertion site appeared red, warm, and swollen?

Discontinue the infusion: An IV site that is red, warm and swollen suggests phlebitis or infection and the IV catheter must be removed to prevent further damage to the patient's arm.

How can the nurse best minimize the patient's risk for infection when administering an IV bolus of an analgesic?

Follow aseptic technique during the entire process.

Which action will the nurse take to minimize a patient's risk for injury when applying a dressing to an infusion site?

Following aseptic technique throughout the dressing application will minimize the patient's risk for injury related to infection

When administering an IV piggyback medication to infuse by gravity, how can the nurse ensure that the medication will flow properly?

Hang the piggyback medication higher than the primary fluid.

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?

Informs the nurse and other staff when the next dressing change is due: 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.

A patient for whom an intravenous antibiotic is prescribed has a multilumen central line in place for central parenteral nutrition (CPN). What should the nurse do?

Infuse the antibiotic through another lumen of the multilumen central line.

The nurse is inserting an over-the-needle catheter into a newly admitted patient. What will the nurse do after confirming blood return?

Lowering the catheter until it is flush with the skin minimizes the risk of passing the needle through the opposite vessel wall.

After unsuccessfully attempting to flush a nasogastric (NG) tube with water, what is the most appropriate action for the nurse to take?

Obtain a product designed to unclog NG tubes.

The nurse is concerned that a patient's central venous access device (CVAD) may have become dislodged. How might the nurse assess for this complication?

Palpate the skin for coiling.

What is the proper response to the nurse's observation that the patient's closed-system enteral feeding has 150 mL of formula remaining and that the infusion order rate is for 50 mL/hr?

Plan to check the feeding for completion within the next 3 hours.

What will the nurse do after removing the soiled dressing from a patient's CVAD device?

Remove the catheter stabilization device, if present.

ow can the nurse minimize the risk of dislodging the catheter when removing a dressing?

Remove the transparent dressing or tape and gauze in the direction of catheter insertion.

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?

Restart the IV in another location less affected by the patient's positioning.

While checking a blood product prior to administration, the nurse is called away to assist with another procedure. What should the nurse do with the blood product?

Return it to the blood bank until it can be administered.

How can the nurse ensure that a patient's IV tubing will not tug on the infusion catheter after a transparent dressing is applied to an infusion site on the arm?

Secure the tubing in two different locations on the arm.

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?

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.

How would the infusion of intravenous (IV) fluids be affected if the tubing were unintentionally dislodged from the chamber of the control mechanism of the electronic infusion device (EID)?

The fluid would stop, because an anti-free-flow safeguard on the EID tubing would stop the flow of fluids.

It is determined that a patient who received a blood transfusion received an infection from the blood. Whom should the nurse notify of this infection?

The nurse should report sepsis and other transfusion-related infections to the blood bank and to the agency's infection control department.

While changing a patient's hospital gown, the extension set on the IV infusion becomes disconnected and ends up on the bed linens. What would the nurse do?

The nurse would change the contaminated extension set tubing.

A patient prescribed to receive two units of packed red blood cells is to receive a dose of intravenous medication between the two units. How would the nurse administer the medication?

Through another IV line

A patient experiencing a blood transfusion reaction is prescribed to receive epinephrine. What is the purpose of this medication when given for this indication?

To relieve respiratory distress

After changing the intravenous tubing on a patient's primary infusion, the nurse notes air bubbles in the tubing. How would the nurse remove them?

To remove air bubbles from the tubing, the nurse would close the roller clamp, stretch the tubing downward, and flick the tubing, so that the air bubbles will rise into the drip chamber.

When drawing blood from a patient's central venous access device (CVAD), what can the nurse do to minimize pressure on the device during flushing?

Use a 10-mL syringe for the flush.

Which action would the nurse take to minimize the patient's risk for infection when changing the dressing on a CVAD?

Use sterile technique throughout the process.

A patient is to receive 3 units of packed red blood cells over 8 hours. What will the nurse do to maintain the patency of the patient's IV access line after each of the first two units of blood has transfused?

When consecutive units are to be given, the patency of the IV line is maintained with 0.9% normal saline infusing at the KVO rate.

While checking a blood bag prior to infusion, the nurse notes that the patient's blood type is A+ and the donor's blood type is O+. Which action would the nurse take?

administer the blood: A patient whose blood type is A+ can receive blood from a donor whose blood type is O+.

which technique is MOST accurate in identifying an appropriate vein site for IV catheter insertion into the arm?

apply a tourniquet to selected arm 4-6 inches above proposed site

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?

apply warm compress: An IV site with evidence of phlebitis is to be wrapped with a warm compress.

When drawing blood from a central venous access device (CVAD) in which all ports are patent, it is recommended that the nurse select which lumen?

distal port

A patient receiving a unit of blood begins to show signs of a transfusion reaction. How frequently should the nurse monitor the patient's vital signs after stopping the transfusion?

every 15 minutes

a nurse assessing the IV site of a patient observes swelling and pain around the site, and notes significant decrease in flow rate. the patient complains of coldness around the infusion site. what IV complication does this describe?

infiltration

a nurse prepares to insert an NG tube to provide nutrition to pt. which of the following is a recommended guideline for this procedure?

measure tube from tip of nose to ear lobe and from ear lob to xiphoid process

a patient w/ dehydration is being administered IV fluids. during rounds, the nurse noticed that the skin immediately surrounding IV site was reddish in color and tender to touch (showing signs of inflammation). the nurse recognizes that what phenomenon is likely responsible?

phlebitis