ati iv, phleb, burns
A nurse is monitoring the fluid replacement of a client who has sustained burns. Which of the following fluids is used in the 1st 24hr following a burn injury?
Lactated Ringer's
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 IV insertion site?
"The area surrounding the insertion site feels warm to the touch"
A nurse is preparing to insert an IV catheter for a client and has selected the insertion site. Place the following steps in the order in which the nurse should perform them. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
After the nurse first applies a tourniquet or BP cuff to help select the vein for the IV infusion, he should remove the device, cleanse the site with soap and water, allow it to dry, and then cleanse it with an antiseptic swab, again allowing it to dry. Then he should reapply the tourniquet or BP cuff, dilate the vein, check for pulsation, then insert the venous access device. After noting a blood return, he should stabilize the catheter, release the tourniquet, flush the catheter, and then secure it.
A nurse in an emergency department is caring for a client who has deep-partial and full-thickness burns to his chest, abdomen and upper arms. What is the nurse's priority intervention for this client during the resuscitation of phase of injury?
Maintain airway
A nurse is caring for a patient who has a central venous catheter and suddenly develops dyspnea, tachycardia, and dizziness. The nurse suspects air embolism and clamps the catheter immediately. The nurse should reposition the patient in which of the following positions?
On his left side in Trendelenburg position
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.
Stop the infusion.Remove the IV catheter.Apply a sterile dressing.Elevate the extremity.Apply warm or cold compresses.
a patient with burns is being prepared for porcine grafts. an advantage of using biologic grafts on burns is that they
promote the growth of epithetial tissue
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
cephalic & basilic
a nurse is caring for a preschooler who has partial-thickness burn on her right forearm. Which of the following findings should the nurse expect?
sensitive to touch wound blanches with pressure blisters
A client has a right subclavian central venous catheter. When reconnecting a new administration set, which of the following instructions should the nurse give the client?
"Bear down while holding breath."The client should perform a Valsalva maneuver by holding a breath and bearing down while the nurse disconnects the old set and reconnects the new set. This action prevents air from entering the lumen, the heart, and pulmonary circulation
A nurse is caring for a client who has burns to his face, ears and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?A. Urinary output 25mL/hrB. Difficulty swallowingC. HR 122 beats/minD. Lip edema
B. Difficulty swallowing
A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as deep partial-thickness burn?
The burned area is red in color with eschar present.
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.rationale: edema, pallor, and coolness around the insertion site indicate a collection of fluid leaking into subcutaneous tissue, aka an infiltration
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?
Cholrhexidine
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?
Discontinue the existing IV line.
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. Which of the following actions should the nurse take first?
Measure the circumference of both upper arms. Correct! Notify the provider who inserted the PICC line. Remove the PICC line. Apply a cold pack to the client's upper arm. The first action the nurse should take using the nursing process is to assess the client. The nurse should measure the arm and compare the result with the circumference of the other arm. If the arm is swollen, the nurse should notify the provider who inserted the PICC line. Swelling could indicate formation of a clot above the site or even catheter rupture.
A nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet . The nurse should recommend which of the following foods as the best source of protein to promote wound healing?
One cup of lentils
A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take?
Remove the catheter and insert another into a different site.
The nurse is caring for a client who has a single lumen central venous catheter. Which of the following actions should the nurse take when assessing the catheter?
Use a 10-mL syringe to flush the catheter.During the flushing procedure, the nurse should use a 10-mL barrel syringe, because the pressure that is exerted by smaller barrel syringes increases the risk for rupturing the catheter.
