unit 3

The nurse is completing a time tape for a 1000-mL IV bag that is scheduled to infuse over 8 hours. The nurse has just placed the 1100 marking at the 500mL level. The nurse would place the mark for noon at which numerical mL on the time tape? answer in mL

375mL pg 159

A client involved in a motor vehicle crash present to the ED with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates which IV solution to be prescribed to increase intravascular volume, replace blood loss volume, and increase blood pressure? -5% dextrose in lactated ringer's -o.33% sodium chloride -0.225% sodium chloride -0.45% sodium chloride

5% dextrose in lactated ringer's pg 160

The nurse provides a list of instructions to a client being discharged to home with a PICC. The nurse determines that the client needs further instructions if the client made which statement? -I need to wear a Medic-Alert tag -I need to restrict my activity while this catheter is in place -I need to have a repair kit available in the home for use if needed -I need to keep the insertion site protected when in the shower or bath

I need to restrict my activity while this catheter is in place pg 160

The nurse is making rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client's IV site is cool, pale, and swollen with the solution not infusing. The nurse concludes that which complication has occurred? -infection -phlebitis -infiltration -thrombosis

infiltration pg 159/160

A client rings the call bell and complains of pain at the site of an IV infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which action(s) in the care of this client? select all that apply: -notify the HCP -remove the IV catheter at that site -apply warm/moist packs to the site -start a new IV in a proximal portion of the same vein -document the occurrence, actions taken, and the client's response

notify the HCP remove the IV catheter at that site apply warm/moist packs to the site document the occurrence, actions taken, and the client's response pg 160

The nurse is preparing a continuous IV infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops, and the spike hits the top of the medication cart. The nurse should take which action? -obtain a new IV bag -obtain new IV tubing -wipe the spike end with Betadine -scrub the spike end with 70% alcohol swab

obtain new IV tubing pg 160

The nurse notes that the site of a clients peripheral IV catheter is red, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse should document in the medical record that the client experienced which condition? -phlebitis of the vein -infiltration to the IV line -hypersensitivity to the IV solution -allergic reaction to the IV catheter material

phlebitis of the vein pg 160

A client has just undergone insertion of a central venous catheter at the bedside. The nurse would be sure to check which results before initiating the flow rate of the client's IV solution at 100mL/hr? -serum osmolality -serum electrolyte levels -portable CXR film -intake and output record

portable CXR film pg 160

The nurse has a prescription to hang a 1000-mL IV bag of 5% dextrose in water with 20mEq of potassium chloride and needs to add the medication to the IV bag. The nurse should plan to take which action immediately after injecting potassium chloride into the port of the IV bag? -rotate the bag gently -attach the tubing to the client -prime the tubing with the IV solution -check the solution for yellow discoloration

rotate the bag gently pg 159

A client had a 1000-mL bag of 5% dextrose to 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, is experiencing chills, and is apprehensive with an increased pulse rate. The IV bag has 400mL remaining. The nurse should take which action first? -slow the IV infusion -sit the client up in bed -remove the IV catheter -Call the HCP

slow the IV infusion pg 159

A HCP has written a prescription to discontinue an IV line. The nurse should obtain which items from the unit supply area for applying pressure to the site after removing the IV catheter? -elastic wrap -Betadine swab -adhesive bandage -sterile 2x2 gauze

sterile 2x2 gauze pg 160

The nurse is inserting an IV line into a vein. After the initial stick, the nurse would continue to advance the catheter in which situation? -the catheter advances easily -the vein is distended under the needle -the client does not complain of discomfort -blood return shows in the back flash chamber of the catheter

blood return shows in the back flash chamber of the catheter pg 160

A client with the recent diagnosis of myocardial infarction and impaired renal function is recuperating on the step-down cardiac unit. The client's BP has been borderline low and IV fluids have been infusing at 100mL/hr via central line catheter in the right internal jugular vein for approx. 24 hours to increase renal output and maintain the blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly, and is coughing. The nurse determines that the client is most likely experiencing which complication to IV therapy? -hematoma -air embolism -systematic infection -circulatory overload

circulatory overload pg 160