Adult Health Exam 1
Hodgkin's lymphoma
distinguished from other lymphomas by the presence of large, cancerous lymphocytes known as Reed-Sternberg cells
chronic pain
episode of pain that lasts for 3-6 months or longer; may be intermittent or continuous
extravasation
escape of blood from the blood vessel into the tissue Pain, stinging, burning, swelling, or redness at the site.
PAC, Hickman's, Broviac's require _______ flushes after each use.
heparin
Non-tunneled catheters have high risk for:
infection
larger syringe =
less pressure
Peripherally Inserted Central Catheters (PICC): ______ term use
long
Tunneled catheters are for _____ term use
long
What are some indications for central lines?
long term antibiotics peripheral sites not great multiple medications use blood sampling
Implanted ports: _____ term use, accessed with:
long, huber
smaller syringe =
more pressure
Ductal estasia
nipple discharge not associated with malignancy
Neuropathic
pain as a result of damage to or dysfunction of nervous system
PICC Inserted in ___________ _____ and threaded to SVC
peripheral vein
multiple myeloma
plasma cell cancer
Managing pneumothorax: Position in: Administer: Prepare for _______ ______ insertion
semi-fowlers 02 chest tube
Subcutaneous tunnel created for _________ _____ down the chest wall
subclavian vein
Non-tunneled catheter's are inserted into
superior vena cava
CVADs should rest in the _______ _______ _________ above the ______ ________
superior vena cava, right atrium
4 general principles for all central lines (SFHC)
syringe size, flushing, heparin flushing, clamping
Peripherally Inserted Central Catheters
A long central catheter that is inserted into the basilica or cephalic vein in the arm. Can have single or multiple lumens. - Indicated for administering fluids, blood, and medications, as well as blood sampling.
A nurse is preparing to insert a peripheral IV catheter. Which of the following antiseptics is the nurse's best choice for preparing the client's skin at the insertion site? A. Alcohol B. Chlorhexidine C. Tincture of iodine D. Povidone-iodine
B. Chlorhexidine
Non-tunneled catheters patient positioned in
trendelenburg
Before using any CVAD, correct placement should always be verified by:
x-ray
A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect? A. The client reports numbness at the site. B. Purulent drainage is noted from the site. C. The vein appears cordlike. D. Skin over the site is sloughing.
B. Purulent drainage is noted from the site.
Describe three ways to select a vein to initiate peripheral IV access
Stroke the extremity gently below the intended IV site. Place a warm blanket/towel on the extremity for a couple of minutes. Select a vein that's well-dilated, soft with palpation, and bounces back when you release the pressure.
Erectogenic
Tadalafil (Cialis) - dec. symptoms
A nurse is teaching a client who is about to undergo the insertion of a nontunneled central venous access device.Which of the following statements should the nurse identify as an indication that the client understands theinstructions?
"I will turn my head in the opposite direction during insertion."
Central lines ALWAYS use a ___ ml or larger syringe
10
Size of IV catheter for adult receiving large quantities of fluids or blood products
18 gauge
Older adult patients with an IV infusion and medication
22 gauge
A nurse is caring for a client who has a central venous catheter and develops acute shortness of breath. Which ofthe following actions should the nurse take first?
A. Clamp the catheter.
While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first? A. Discontinue the existing IV line. B. Initiate a new IV line in the other extremity. C. Apply a hot pack to the irritated site. D. Determine if the client needs to continue IV therapy.
A. Discontinue the existing IV line.
A nurse is assessing a client who has intravenous therapy-related phlebitis. The nurse uses the Infusion Nurses Society's phlebitis scale to assess the severity of phlebitis and documents the client's phlebitis as a grade level 1.Which of the following assessment findings correlates with a grade level of 1? A. Redness at the intravenous access site with pain B. Red streaks on the affected extremity C. Palpable venous cord in the affected extremity D. Purulent drainage at the intravenous site access site
A. Redness at the intravenous access site with pain
A nurse is assessing an older adult client who is receiving IV therapy. The nurse should recognize that which ofthe following findings indicates fluid volume excess? (Select all that apply.) A. Bounding pulse B. Pitting edema C. Swelling at the IV site D. Urine-specific gravity greater than 1.030 E. Crackles upon auscultation
ABE
Visceral pain
Activation of nociceptors in the internal organs and lining of the body cavities
A nurse is assessing a client who has a peripheral IV with a continuous infusion. Which of the following findings isa manifestation of phlebitis? (Select all that apply.) A. Erythema B. Damp dressing C. Throbbing D. Warmth at insertion site E. Streak formation
All but B
A nurse is caring for an adult client who is scheduled for surgery. Which of the following sites should the nurse assess for possible placement of an IV catheter? (Select all that apply.) A. Great saphenous vein B. Cephalic vein C. Dorsal plexus D. Basilic vein E. External jugular vein
B, D
A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IVinsertion site? A. "The infusion rate has stopped but the tubing is not kinked." B. "The area surrounding the insertion site feels warm to the touch." C. "There is fluid leaking around the insertion site." D. "There is no blood return when the tubing is aspirated."
B. "The area surrounding the insertion site feels warm to the touch."
A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which ofthe following solutions should the nurse prepare to infuse for this client? A. Lactated Ringer's (isotonic - low blood volume or low blood pressure) B. Dextrose 5% in 0.9% sodium chloride (hypertonic - hypoglycemia) C. 0.45% sodium chloride (hypotonic IV solution,) D. Dextrose 10% in water (treat low blood sugar (hypoglycemia), insulin shock, or dehydration (hypertonic - fluid loss).
C. 0.45% sodium chloride
A nurse is preparing to insert an IV catheter for a client and has selected the insertion site. Place the followingsteps in the order in which the nurse should perform them. (Move the steps into the box on the right, placing themin the order of performance. Use all the steps.) A. Apply a tourniquet or BP cuff. B. Insert the catheter. C. Cleanse the site with an antiseptic swab. D. Flush the catheter. E. Dilate the vein.
C. Cleanse the site with an antiseptic swab. A. Apply a tourniquet or BP cuff. E. Dilate the vein. B. Insert the catheter. D. Flush the catheter.
A nurse is assessing an IV infusion site on an infant's left hand. Which of the following findings should the nurse identify as an indication of an infiltration? A. Blood in the IV tubing B. Absence of blanching at the insertion site C. Edema in the palm of the hand D. Warmth around the insertion site
C. Edema in the palm of the hand
Do all central lines need to be flushed with heparin? Why do you flush with heparin?
CVADs may require heparin flushing, it helps ensure and maintain patency of the CVAD.
Pneumothorax and Hemothorax
Caused by a lung puncture, possible complications of central venous catheterization. - Dyspnea, hypoxia, tachycardia, restlessness, cyanosis, chest pain, and decreased breath sounds.
Implanted Vascular Access Device
Consists of a single or double injection port with a self-sealing silicone septum covering a metal or plastic reservoir. - Used to administer medication, deliver fluids, and draw blood samples.
client has a right subclavian central venous catheter. When reconnecting a new administration set, which of thefollowing instructions should the nurse give the client?
D. "Bear down while holding breath."
9. A nurse enters an older adult client's room to insert a saline lock. The client asks the nurse, "Why do I need that? Iam drinking plenty of fluids." Which of the following responses should the nurse provide? A. "It is quicker to administer medications intravenously in the hospital." B. "Clients over the age of 65 must have a saline lock according to facility policy." C. "We administer all medications intravenously to clients in this unit." D. "Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours."
D. "Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours."
A nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the following veins should the nurse select? A. Dorsal metacarpal vein B. Radial vein in the wrist C. Antecubital vein D. Median vein in the forearm
D. Median vein in the forearm The bones in the forearm provide naturalsplinting and protection for IV insertion sites in the forearm and allow more freedom of movement for the client.
A nurse is attempting to flush the IV saline lock for a client. The client reports pain above the catheter site. Whichof the following actions should the nurse take? A. Inject the solution more slowly while flushing the IV saline lock. B. Apply a warm compress to the IV site. C. Apply firm pressure to the plunger of the syringe during the IV flush to improve patency. D. Remove the IV saline lock.
D. Remove the IV saline lock.
Tunneled catheters have a _______ ______-purpose is to promote fibrin growth to anchor cath in place
Dacron cuff
Central Line-Associated Blood Stream Infection
Prepare administration site with 0.5% chlorhexidine with alcohol. Change administration sets at least every 7 days, but no more frequently than every 4 days. - Fever, chills, swelling, tenderness, redness, or drainage at the insertion or exit site.
fluid overload
Distended neck veins, increased BP, tachycardia, SOB, crackles in lungs, edema,
Circulatory Overload
Dyspnea, elevated blood pressure, edema, and moist breath sounds.
Transurethral Resection of the Prostate (TURP)
Enter through the urethra Small cuts are made into the prostate to relieve pressure on the urethra
5-alpha Reductase Inhibitors
Finasteride (Proscar) Dutasteride (Avodart)
Catheter Malposition (Migration)
Fluid flow against the direction of blood flow.
Tunneled catheters names
Hickman, Broviac, Groshong
What happens if a central line is open to air? How do you prevent air from entering the patient's central circulation?
If a central line is open to air it may cause an embolus, to prevent this ensure the central lines are clamped.
Tunneled Catheters
Inserted under the skin in the chest region and threaded into a large vessel so the tip rests in the superior vena cava. - Used for administering fluids, chemotherapy, antibiotics, blood, parenteral nutrition. - long-term
PQRST
P: Precipitating cause Q: Quality R: Region S: Severity T: Timing
somatic pain
Pain that originates from skeletal muscles, ligaments, or joints. (superficial or deep)
superficial pain
Pain that originates from the skin or mucous membranes; opposite of deep pain.
Phlebitis
Pain, increased skin temperature, and redness along vein.
Phlebitis
Pain, increased skin temperature, and redness along vein. (vein inflammation)
Extravasation
Pain, stinging, burning, swelling, or redness at the site.
brachytherapy
Radioactive seeds implanted Radiation directly to tissue while sparing surrounding tissue
Infection
Redness, swelling, warmth to touch, purulent drainage.
A nurse is caring for client who has a single lumen central venous catheter. Which of the following actions shouldthe nurse take when accessing the catheter?
Use a 10-mL syringe to flush the catheter.
Non-Hodgkin's Lymphoma
a malignant cancer that starts in the lymphocytes; includes any type of lymphoma except Hodgkin's lymphoma
Flush central line with ___ of sterile 0.9% sodium chloride to ensure patency every 8 hours
3-5 ml
Hematoma
a solid swelling of clotted blood within the tissues. - Maintain pressure for 3-5 minutes after catheter removal
proximal lumen
administer meds and blood
prostate cancer risk factors
age, ancestry, family history, farmers african Americans
Catheter Rupture
Fluid leaking around the site, pain or swelling during an infusion, or inability to aspirate blood.
distal lumen
Used for the administration of blood or other viscous fluids
What type of solution should be used to flush central lines? When should you flush central lines? Why should you use the pulsing method?
0.9& sodium chloride solution helps ensure and maintain patency of all types of CVADs.
Alpha 1 Selective Blocking Agents
Doxazosin (Cardura) Prazosin (Minipress) Tamsulosin (Flomax) Relax smooth muscle of the prostate that surrounds urethra
circulatory overload
Dyspnea, elevated blood pressure, edema, and moist breath sounds.
Thrombosis
Look for clotting inside the lumen or outside around the caterer tip that blocks the catheter's lumen. This can make it impossible to draw blood from the catheter. - Swelling of the forearm.
catheter embolus
Missing cath tip when discontinuingSevere pain at site of migration - place tourniquet high
After removing the intravenous catheter, you notice signs of infection. What are you worried about? What will you do?
Notify the provider immediately and obtain a specimen for culture from the insertion site. Cut off the tip of the IV catheter and place it in a sterile container.
acute pain
pain that is felt suddenly from injury, disease, trauma, or surgery
deep pain
pain that occurs in tissues below skin level; opposite of superficial pain
middle lumen
parenteral nutrition
Size of IV catheter for adult with an IV infusion and medications
20-22 gauge
Child with an IV infusion and medications
22-26 gauge
If accessed or in use, needle and dressing of implanted port must be changed every ___ days and if not accessed __ days
7, 30
CVAD Flush with NS every _____ hours, after blood sampling, and with med administration
8-12
A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain inthe insertion area. Which of the following actions should the nurse take? A. Remove the catheter and insert another into a different site. B. Administer an analgesic PO. C. Request a prescription for placement of a central venous access device. D. Administer a local anesthetic.
A. Remove the catheter and insert another into a different site.
A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions. (Move the steps into the box on the right, placing them in the selected order ofperformance. All steps must be used.) A. Elevate the extremity. B. Stop the infusion. C. Apply warm or cold compresses. D. Remove the IV catheter. E. Apply a sterile dressing.
B. Stop the infusion. D. Remove the IV catheter. E. Apply a sterile dressing. A. Elevate the extremity. C. Apply warm or cold compresses.
A charge nurse is teaching a new nurse how to initiate IV access on a client. Which of the following actions by the new nurse indicates an understanding of the teaching? A. Shaves the selected insertion site with a razor prior to the procedure. B. Washes hands with soap and water before the procedure C. Applies sterile gloves prior to inserting the IV catheter D. Applies the tourniquet 1 inch above the selected insertion site
B. Washes hands with soap and water before the procedure
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? A. BP B. Heart rate C. Urine output D. Weight
B. heart rate
Infiltration
Edema, pallor, decreased skin temperature around the site, and pain.
Nontunneled CVADs
Generally used for short-term therapy, the most common insertion site is the internal or subclavian vein. - can be inserted into femoral vein - Used for Intravenous therapy, blood sampling, and central venous pressure monitoring.
Air Embolism
Listen for a churning noise during assessment and auscultation over the pericardium. - The client may develop dyspnea, chest pain, tachycardia, hypotension, anxiety, nausea, dizziness and confusion.
Lumen Occlusion
Look for possible occlusions caused by medicine precipitate and lipid sludge. - Occlusions, thrombus.
A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter(PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Whichof the following actions should the nurse take first?
Measure the circumference of both upper arms.
After removing an intravenous catheter, you inspect the tip and notice the end is missing. What are you worried about? What will you do?
Notify the provider immediately because a catheter that broke off in the vein has the potential to cause an embolus. Apply a tourniquet high on the extremity where the IV line was located and follow facility policy for further intervention.
A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea,dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What otheraction should the nurse take at this time?
Place the client on his left side in Trendelenburg position.
What size of syringe can be used with central lines? Why? What can happen if you flush with a 3 ml syringe?
Use only 10 mL or larger syringes because excessive pressure can rupture the catheter.
Intraductal papilloma
benign, soft wart-like growths in mammary ducts
Tamoxifen
blocks estrogen receptors (mood swings, vaginal dryness, hot flashes) Increased risk for—blood clots, cataracts, stroke, and endometrial cancers
Embolism management Clamp: Apply: Place on left side in: Notify doctor
cath 02 trendelenburg
infiltration
catheter dislodges swollen, PALE, cool to touch, damp dressing, apply cold/warm compress
nurse is caring for a client who has a central venous catheter and reports hearing a gurgling sound on the side ofthe catheter insertion. Which of the following complications should the nurse suspect?
catheter migration
Fibrocystic breast alterations
characterized by changes in tissue (benign condition)
Catheter related infection Local: Culture ________ from site, Apply warm, moist, compress, Remove catheter if indicated Systemic: Take ________ cultures, give antibiotics, give antipyretics, remove cath
drainage blood
Catheter occlusion management: what would you do? Instruct patient to change positions, _____ _____, and cough Undo ________ or kink in line Flush with ___. Do NOT force. Instill ___________ or __________ to unclog
raise arm clamp NS anticoagulant, thrombolytic
Catheter migration protocol Assist with _________ and new placement of CVAD *If line pulled out: cover with air occlusive dressing; place in left Trendelenburg, call HCP
removal
Non-tunneled catheters: _______ term use and are used often in ___________.
short emergencies
Fibroadenoma
small, painless lumps, well-delineated
