Ch. 15 and 37

The nurse is teaching a client who is being discharged about care for a peripherally inserted central catheter (PICC) line. Which client statement indicates a need for further education? "I can continue my 20-mile (32-km) running schedule as I have in the past." "I can still go about my normal activities of daily living." "I have less chance of getting an infection because the line is not in my hand." "The PICC line can stay in for months."

"I can continue my 20-mile (32-km) running schedule as I have in the past." The statement by the client stating that his or her normal running schedule can continue indicates a need for further education. Excessive physical activity can dislodge the PICC or lead to catheter occlusion and should be avoided.Clients with PICCs should be able to perform normal activities of daily living. PICCs have lower complication rates because the insertion site is in the upper extremity. The dry skin of the arm has fewer types and numbers of microorganisms, leading to lower rates of infection. PICC lines can be used long term (months).

The nurse is inserting a peripheral intravenous (IV) catheter. Which client statement is of greatest concern during this procedure? "I hate having IVs started." "It hurts when you are inserting the line." "My hand tingles when you poke me." "My IV lines never last very long."

"My hand tingles when you poke me." The client's statement about a tingling feeling indicates possible nerve puncture and is of greatest concern to the nurse. To avoid further nerve damage, the nurse should stop immediately, remove the IV catheter, and choose a new site.Statements such as, "I hate having IVs started," "It hurts when you are inserting the line," and "My IVs never last very long," are addressed with teaching about the importance of proper protection of the site.

20 gauge

(1- to 1¼-inch length) Indications: Adequate for all therapies Most providers of anesthesia prefer not to use a smaller size than this for surgery cases Approximate Flow Rates: 65 mL/min (3900 mL/hr)

Be sure to refer to agency policy and give extra attention to heparin concentration. Use __________________ to flush before and after medication administration; ________________ after drawing blood.

10 mL of sterile saline; 20 mL of sterile saline flush

Always use a ________ syringe when flushing PICC lines because a smaller syringe creates higher pressure, which could rupture the lumen of the PICC. The PICC line would be accessed with a needleless syringe.

10-mL

Always use _____________________ to flush any central line because the pressure exerted by a smaller barrel poses a risk for rupturing the catheter.

10-mL barrel syringes

A 22-year-old client presents with appendicitis and is preparing for surgery. What gauge catheter will the ED nurse select for this client? 24 22 18 14

18 An 18-gauge catheter is the size of choice for clients who will undergo surgery. If they need to receive fluids rapidly, or if they need to receive more viscous fluids (such as blood or blood products), a lumen of this size would accommodate those needs.Neither a 24-gauge nor a 22-gauge catheter is an appropriate size (too small) for clients who will undergo surgery. If it becomes necessary to administer fluids to the client rapidly, another IV would be needed with a larger needle—18, for example. Administering through the smallest gauge necessary is usually best practice, unless the client may be going into hypovolemic status (shock). A 14-gauge catheter is an extremely large-gauge needle that is very damaging to the vein.

1 kg = ? lbs

2.2 lbs

normal HCO3

22-26 mEq/L

normal paCO2

35-45 mmHg

Drugs such as amiodarone, vancomycin, and ciprofloxacin are venous irritants that have a pH less than

5.0 Phlebitis can occur when patients require long-term infusion of these drugs in peripheral circulation.

normal paO2

80-100 mmHg

A client with polycythemia vera is admitted with shortness of breath, hypertension, and loss of pulses in the right foot. Which nursing intervention is the priority? A. Assess hydration status B. Evaluate for hypertensive crisis C. Elevate lower extremities on pillows D. Use soft-bristle toothbrush to prevent bleeding

ANS: A Polycythemia vera, a form of malignant RBC hyperproduction and clotting factor dysfunction, requires evaluation of intravascular hydration, preparation of laboratory tests for possible therapeutic phlebotomy, and anticoagulant therapy to decrease clots. clients with this disease are at risk of hypertension and experience poor tissue oxygenation as well, requiring assessment. Raising lower extremities may assist with perfusion and symptoms but would not be a priority in this scenario. Using a soft-bristle toothbrush is helpful to prevent bleeding, yet hydration is still the priority.

During IV catheter insertion, a client with dehydration reports feeling "pins and needles" in the arm. What is the appropriate nursing response? A."Nerve puncture may have occurred." B."That is a normal sensation that will go away." C."It is likely that the vein I was accessing has collapsed." D."That means that the catheter is placed in the appropriate location."

ANS: A Reports of tingling, feeling "pins and needles" in the extremity, or numbness during the venipuncture procedure can indicate nerve puncture. The procedure should be stopped immediately, the catheter removed, and a new site chosen. Transsection of the nerve can result in permanent loss of function, and local nerve damage can become a chronic systemic pain syndrome.

What is the priority nursing intervention when caring for an older client with a history of diverticular disease and pernicious anemia? A.Preventing falls B.Monitoring intake and output C.Turning the client every 2 hours D.Encouraging a diet high in vitamin B12

ANS: A The client will have difficulty absorbing vitamin B12 because of diverticular disease and may have developed paresthesia in the feet, increasing the risk for falls. Anemia may also increase the client's symptom of weakness, thereby increasing fall risk. Preventing falls is a priority intervention in the care of older clients. All other interventions can take place after safety has been ensured.

A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement will the nurse include in this client's teaching? a. "Avoid carrying your grandchild with the arm that has the central catheter." b. "Be sure to place the arm with the central catheter in a sling during the day." c. "Flush the peripherally inserted central catheter line with normal saline daily." d. "You can use the arm with the central catheter for most activities of daily living."

ANS: A A properly placed PICC (in the antecubital fossa or the basilic vein) allows the client considerable freedom of movement. Clients can participate in most activities of daily living; however, heavy lifting can dislodge the catheter or occlude the lumen. Although it is important to keep the insertion site and tubing dry, the client can shower. The device is flushed with heparin.

While assessing a client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 1.5 inch (4-cm) venous cord. How will the nurse document this finding? a. "Grade 3 phlebitis at IV site" b. "Infection at IV site" c. "Thrombosed area at IV site" d. "Infiltration at IV site"

ANS: A The presence of a red streak and palpable cord indicates grade 3 phlebitis. No information in the description indicates that infection, thrombosis, or infiltration is present.

The nurse is preparing to administer a blood transfusion. Which action(s) by the nurse is (are) most appropriate? (Select all that apply.) a. Hang the blood product using normal saline and a filtered tubing set. b. Take a full set of vital signs prior to starting the blood transfusion. c. Tell the client that someone will remain at the bedside for the first 5 minutes. d. Use gloves to start the client's IV if needed and to handle the blood product. e. Verify the client's identity, and checking blood compatibility and expiration time.

ANS: A, B, D Correct actions prior to beginning a blood transfusion include hanging the product with saline and the correct filtered blood tubing, taking a full set of vital signs prior to starting, and using gloves. Someone stays with the client for the first 15 to 20 minutes of the transfusion. Two registered nurses must verify the client's identity and blood compatibility.

A nurse assists with the insertion of a central vascular access device. Which actions will the nurse ensure are completed to prevent a catheter-related bloodstream infection? (Select all that apply.) a. Include a review for the need of the device each day in the client's plan of care. b. Remind the primary health care provider to perform hand hygiene prior to insertion if he or she forgets. c. Cleanse the preferred site with alcohol and let it dry completely before insertion. d. Ask everyone in the room to wear a surgical mask during the procedure. e. Plan to complete a sterile dressing change on the device every day. f. Minimal client draping and barrier precautions as blood loss are minimal.

ANS: A, B, D The central vascular access device bundle to prevent catheter-related bloodstream infections includes using a checklist during insertion, performing hand hygiene before inserting the catheter and anytime someone touches the catheter, using chlorhexidine to disinfect the skin at the site of insertion, using preferred sites, and reviewing the need for the catheter every day. The practitioner who inserts the device would wear sterile gloves, gown, and mask, and anyone in the room would wear a mask. Maximal barrier precautions are used which requires the client to be draped sterilely from head to toe. The initial dressing on a central vascular access device is changed in 24 hours. Gauze and tape dressings are changed every 48 hours and transparent membrane dressings are changed every 5 to 7 days.

The nurse is caring for a client receiving a unit of whole blood. Which nursing action(s) is (are) appropriate regarding infusion administration. (Select all that apply.) a. Use a dedicated filtered blood administration set. b. Stay with the client for the first 15 to 20 minutes of the infusion. c. Infuse the blood over a 30-minute period of time. d. Monitor and document vital signs per agency policy. e. Use a 21-gauge or smaller catheter to administer the blood. f. Infuse the transfusion with intravenous normal saline.

ANS: A, B, D, F Blood administration requires a dedicated and filtered intravenous set and a larger catheter or needle due to the viscosity of the infusion. Normal saline is the only IV fluid that is compatible with blood. Vital signs are frequently monitored and documented while the client is carefully assesses for signs and symptoms of a blood transfusion reaction, usually within the first 15 to 20 minutes. One unit of blood is administered in no less than 60 minutes.

A nurse is caring for an older adult receiving multiple packed red blood cell transfusions. Which assessment finding(s) indicate(s) possible transfusion circulatory overload? (Select all that apply.) a. Acute confusion b. Dyspnea c. Depression d. Hypertension e. Bradycardia f. Bounding pulse

ANS: A, B, D, F Circulatory overload is the result of excessive body fluid which can cause signs and symptoms of heart failure including dyspnea, increased blood pressure, tachycardia (not bradycardia), and a bounding pulse. Dyspnea is caused by hypoxia which in older adults can cause acute confusion. Depression is not a common finding resulting from fluid overload.

A nurse prepares to insert a short peripheral venous catheter. What actions will the nurse take to use best practices? (Select all that apply.) a. Choose a distal site on the client's nondominant arm. b. Verify that the prescription is appropriate for peripheral infusion. c. Place the venous catheter near an area of joint flexion. d. Wear a surgical mask during the catheter insertion procedure. e. Perform hand hygiene before inserting the catheter. f. Limit unsuccessful attempts by up to three clinicians to one attempt each.

ANS: A, B, E Best practices for the insertion of a short peripheral venous catheter include hand hygiene prior to the procedure, verification of the prescription for intravenous therapy and its appropriateness for infusion through a short peripheral catheter, and placement of the catheter in a distal site, away from an area of joint flexion and when possible in the client's nondominant arm. Surgical masks are needed for central venous catheter placement but not for short peripheral venous catheter placement. Unsuccessful attempts to insert the catheter should be limited to two per person and no more than four total.

A nurse is preparing to administer a packed red blood cell transfusion to an older adult. Understanding age-related changes, what alteration(s) in the usual protocol is (are) necessary for the nurse to implement? (Select all that apply.) a. Assess vital signs at least every 15 minutes. b. Avoid giving other IV fluids. c. Pre-medicate to prevent transfusion reaction. d. Transfuse smaller bags of blood. e. Transfuse each unit over 8 hours. f. Assess the client for fluid overload.

ANS: A, B, F The older adult needs vital signs monitored as often as every 15 minutes for the duration of the transfusion because vital sign changes may be the only indication of a transfusion-related problem. To prevent fluid overload, the nurse obtains a prescription to hold other running IV fluids during the transfusion and assesses the client frequently for signs and symptoms of overload. The other options are not correct.

A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which common complications will the nurse assess? (Select all that apply.) a. Phlebitis b. Pneumothorax c. Thrombophlebitis d. Excessive bleeding e. Extravasation f. Pneumothorax g. Infiltration

ANS: A, C Although the complication rate with PICCs is fairly low, the most common complications are phlebitis, thrombophlebitis, and catheter-related bloodstream infection. Excessive bleeding, infiltration, and extravasation are not common complications. Pneumothorax does not occur.

A 33-year-old client with a history of sickle cell disease had an emergent open reduction and internal fixation of the right femur after a car crash. Which nursing intervention is the priority following surgery? A.Treating pain B.Ensuring adequate IV hydration C.Titrating oxygen to Spo2 > 95% D.Examining the surgical incision for infection

ANS: B Anesthesia and stress can precipitate a sickle cell crisis. Adequate hydration is a postoperative priority to support vital signs, as well as treat sickle cell symptoms and sickle cell-associated pain. Effective hydration will augment additional pain management strategies necessary for treating sickle cell pain and postoperative pain. Ensuring adequate oxygenation is also important because hypoxemia initiates or worsens the sickling of cells. Examination of the surgical site can continue after hydration is ensured.

A new nurse is preparing to insert a vascular access device in a client. Which action by the new nurse requires intervention by the experienced nurse? A.Performing hand hygiene prior to insertion. B.Preparing for insertion immediately following cleaning with iodophors. C.Using friction to clean the skin around the insertion site. D.Clipping the hairs in the preferred insertion area.

ANS: B Current recommendations call for using friction when cleaning the skin to penetrate the layers of the epidermis. Iodophors such as povidone-iodine require contact with the skin for a minimum of 2 minutes to be effective. Skin should never be shaved before venipuncture, but excessive amounts of hair should be clipped.

A nurse is caring for a client who has just had a central venous access line inserted. What action will the nurse take next? a. Begin the prescribed infusion via the new access. b. Ensure that an x-ray is completed to confirm placement. c. Check medication calculations with a second RN. d. Make sure that the solution is appropriate for a central line.

ANS: B A central venous access device, once placed, needs an x-ray confirmation of proper placement before it is used. The bedside nurse would be responsible for beginning the infusion once placement has been verified. Any IV solution can be given through a central line.

A nurse is preparing to administer a blood transfusion. What action is most important? a. Correctly identify client using two identifiers. b. Ensure that informed consent is obtained. c. Hang the blood product with Ringer's lactate. d. Stay with the client for the entire transfusion.

ANS: B If the facility requires informed consent for transfusions, this action is most important because it precedes the other actions taken during the transfusion. Correctly identifying the client and blood product is a National Patient Safety Goal, and is the most important action after obtaining informed consent. Ringer's lactate is not used to transfuse blood. The nurse does not need to stay with the client for the duration of the transfusion.

A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important? a. Document the events in the client's medical record. b. Double-check the client and blood product identification. c. Place the client on strict bedrest until the pain subsides. d. Review the client's medical record for known allergies.

ANS: B This client most likely had a hemolytic transfusion reaction, most commonly caused by blood type or Rh incompatibility. The nurse should double-check all identifying information for both the client and blood type. Documentation occurs after the client is stable. Bedrest may or may not be needed. Allergies to medications or environmental items are not related.

A client with severe burns over 85% of the body is being transported to the ED. The paramedic tells the nurse over the phone that IV access could not be established in the field. What type of IV device does the nurse anticipate will be ordered upon the client's arrival? A.PICC line B.Central line C.Intraosseous catheter D.Subcutaneous infusion

ANS: C Intraosseous (IO) therapy allows access to the rich vascular network located in the long bones. Victims of trauma, burns, cardiac arrest, and other life-threatening conditions benefit from this therapy because often clinicians are unable to access these clients' vascular systems for traditional IV therapy. If IV access cannot be obtained within the first few minutes of resuscitation procedures, IO may be attempted. After establishing IO access, efforts should continue to obtain IV access as well.

A nurse assesses a client who has a radial artery catheter. Which assessment will the nurse complete first? a. Amount of pressure in fluid container b. Date of catheter tubing change c. Type of dressing over the site d. Skin color and capillary refill

ANS: D An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased perfusion to the extremity. Assessment of color, warmth, sensation, capillary refill time, and distal pulses (if appropriate) are assessments for circulation distal to the catheter site. The nurse would note that there is enough pressure in the fluid container to keep the system flushed, and would check to see whether the catheter tubing needs to be changed. However, these are not assessments of greatest concern. The type of dressing over the site would be noted and most likely prescribed by policy.

A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern? a. The catheter has been in place for 20 hours. b. The client has poor vascular access in the upper extremities. c. The catheter is placed in the proximal tibia. d. The client's left lower extremity is cool to the touch.

ANS: D Compartment syndrome is a condition in which increased tissue pressure in a confined anatomic space causes decreased blood flow to the area. A cool extremity can signal the possibility of this syndrome. All other findings are important; however, the possible development of compartment syndrome requires immediate intervention because the client could require amputation of the limb if the nurse does not correctly assess and respond to this perfusion problem.

A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. What action will the nurse take next? a. Apply cold compresses to the IV site. b. Elevate the extremity on a pillow. c. Flush the catheter with normal saline. d. Stop the infusion of intravenous fluids.

ANS: D Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of infiltration include edema and tenderness above the site. The nurse would stop the infusion and remove the catheter. Cold compresses and elevation of the extremity can be done after the catheter is discontinued to increase client comfort. Alternatively, warm compresses may be prescribed per institutional policy and may help speed circulation to the area.

A nurse prepares to insert a peripheral venous catheter in an older adult. What action will the nurse take to protect the client's skin during this procedure? a. Lower the extremity below the level of the heart. b. Apply warm compresses to the extremity. c. Tap the skin lightly and avoid slapping. d. Place a washcloth between the skin and tourniquet.

ANS: D To protect the client's skin, the nurse will place a washcloth or the client's gown between the skin and tourniquet. The other interventions are methods to distend the vein but will not protect the client's skin.

A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention? a. The initial site dressing is 3 days old. b. The PICC was inserted 4 weeks ago. c. A securement device is absent. d. Upper extremity swelling is noted.

ANS: D Upper extremity swelling could indicate infiltration, and the PICC will need to be removed. The initial dressing over the PICC site would be changed within 24 hours. This does not require immediate attention, but the swelling does. The dwell time for PICCs can be months or even years. Securement devices are being used more often now to secure the catheter in place and prevent complications such as phlebitis and infiltration. The IV lacking one does not take priority over the client whose arm is swollen.

Which client does the charge nurse on a medical-surgical unit assign to the LPN/LVN? A client who has a diltiazem IV infusion being titrated to maintain a heart rate between 60 and 80 beats/min. A client admitted for hyperglycemia who has an IV insulin drip and needs frequent glucose checks. An older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours. A client receiving blood products after excessive blood loss during surgery.

An older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours. The older client admitted for confusion with a heparin lock is the most stable and requires basic monitoring of the IV site for common complications such as phlebitis and local infection, which would be familiar to an LPN/LVN.The client with a diltiazem IV infusion, the client with an IV insulin drip, and the client receiving blood products all are not stable and will require ongoing assessments and adjustments in IV therapy that should be performed by an RN.

The nurse is preparing to administer Ancef 1 g in 100 mL D5W IVPB as ordered. The order states the patient should receive the entire dose over 45 minutes. What is the flow rate in mL/hr?

Answer: 133 ml/hr

The patient is to receive 0.45 % NaCl 700 mL IV infusion over 8 hours. The infusion set drop factor is 40 gtts/mL. What is the infusion rate in gtt/min?

Answer: 58 mL

A client is being admitted to the burn unit from another hospital. According to the client's medical record, the client has an intraosseous IV that was started 2 days ago. Which nursing action is most appropriate? Anticipate an order to discontinue the intraosseous IV. Call the previous hospital to verify the date. Immediately discontinue the intraosseous IV. Start an epidural IV.

Anticipate an order to discontinue the intraosseous IV. The admitting nurse would first anticipate an order to discontinue the intraosseous IV and then start an epidural IV. The intraosseous route should be used only during the immediate period of resuscitation and should not be used for longer than 24 hours. Alternative IV routes, such as epidural access, should then be considered for pain management.The nurse should know what to do in this client's situation without contacting the previous hospital. Other client data, such as the date and time that the burn occurred, should validate the date and time of insertion of the IV. Discontinuing the IV is not the priority in this situation—the client is in a precarious fluid balance situation. One IV access should not be stopped until another is established. This type of IV is not used for long-term therapy; an action must be taken.

The nurse is starting a peripheral IV catheter on a client who was recently admitted. What actions does the nurse perform before insertion of the line? (Select all that apply.) Apply povidone-iodine to clean skin, dry for 2 minutes. Clean the skin around the site. Prepare the skin with 70% alcohol or chlorhexidine. Shave the hair around the area of insertion. Wear clean gloves and touch the site only with fingertips after applying antiseptics.

Apply povidone-iodine to clean skin, dry for 2 minutes. Clean the skin around the site. Prepare the skin with 70% alcohol or chlorhexidine. Povidone-iodine (Betadine) is applied to the selected insertion site before insertion. The solution is allowed to dry, which takes about 2 minutes. The insertion site should be cleansed before the antiseptic skin preparations are completed. After soap and water cleansing, prepping with 70% alcohol or chlorhexidine is done.Clipping, rather than shaving, hair around the selected IV site is done. Shaving is abrasive and makes the skin more vulnerable to infection (i.e., microbial invasion). The insertion site should not be palpated again after it has been prepped; this mistake is frequently made with IV starts.

Bedside safety considerations

Assess IV solution, rate, tubing, insertion sites Q1 hr When caring for pts w/ IV fluids and/or meds- note what IV therapy is ordered, verify solution is infusion at correct rate and appropriate amount is in bag, make sure drip chamber is ½ full and IV is dripping, examine tubing for kinks or loose connections, check date on tubing and signs of complications, make sure dressing is clean/dry/intact, note date of insertion Local complications (15.3 and description of each): infiltration, phlebitis during and post-infusion, thrombosis, thrombophlebitis, ecchymosis and hematoma, site infection, venous spasm, nerve damage, extravasation, site infection, Systemic complications (15.4 and description of each: circulatory overload, speed shock, catheter embolism Have new IV bag ready when you change shifts

A client had a 20-gauge short peripheral catheter (SPC) inserted for antibiotic administration 48 hours ago. Which nursing intervention is appropriate? Discontinue the SPC. Relocate the SPC for infection control. Assess the SPC for redness, swelling, or pain. Change the occlusive dressing covering the SPC.

Assess the SPC for redness, swelling, or pain. It is important for the nurse to assess the SPC for signs of infection or infiltration which include redness, swelling, and pain. The nurse would not discontinue the SPC as there is no indication in the stem that the client has concluded IV therapy. It is no longer common practice to relocate SPCs based on a 48-hour time frame. If the site assessed is free from signs of infection or infiltration, relocating the site is not warranted. Changing the dressing should only be done when relocating an IV or when the dressing is visible soiled.

The nurse who is starting the shift finds a client with an IV that is leaking all over the bed linens. What will the nurse do first? Assess the insertion site. Check connections. Check the infusion rate. Discontinue the IV and start another.

Assess the insertion site. The initial response by the nurse is to assess the insertion site. The purpose of this action is to check for patency, which is the priority. IV assessments typically begin at the insertion site and move "up" the line from the insertion site to the tubing, to the tubing's connection to the bag.Checking the IV connection is important, but is not the priority in this situation. Checking the infusion rate is not the priority. Discontinuing the IV to start another may be required, but it may be possible to "save" the IV, and the problem may be positional or involve a loose connection.

PICC- when do you use it? and what safety precautions do you take when inserting?

Central IV placed into antecubital or basilic vein and tip ends near SVC and RA junction, confirm w/ xray nurses need special training insert early in therapy, before veins become damaged phlebitis, thrombophlebitis, DVT (use smallest possible French size), CRBSI/CLABSI PNEUMOTHORAX DOES NOT OCCUR can be used for blood sampling w/ right precautions can use any type of pH or osmolarity, can administer lengthy courses of antibiotics, chemo, parenteral nutrition, vasopressor agents flush w/ heparin daily if not actively in use and nonvalved, weekly if valved Use 10 mL of sterile saline to flush before and after medication administration; 20 mL of sterile saline flush after drawing blood. Always use 10-mL barrel syringes to flush any central line because the pressure exerted by a smaller barrel poses a risk for rupturing the catheter.

The nurse is admitting clients to the same-day surgery unit. Which insertion site for routine peripheral venous catheters will the nurse choose most often? Back of the hand Cephalic vein of the forearm Palmer side of the wrist Subclavian vein

Cephalic vein of the forearm The cephalic vein of the forearm is the insertion site chosen most often. For same-day surgery, the cephalic or basilic vein allows insertion of a larger IV catheter while allowing movement of the arm without impairing intravenous flow.Peripheral venous catheters should never be inserted into the back of the hand in an older adult because the veins are brittle. Peripheral venous catheters are not inserted into the palmar side of the wrist because the median nerve is located close to this area. Catheters are typically inserted into the subclavian vein by the health care provider, not by the nurse.

A client who is receiving intravenous antibiotic treatments every 6 hours has an intermittent IV set that was opened 20 hours ago. What action will the nurse take? Change the set immediately. Change the set in about 4 hours. Change the set in the next 12 to 24 hours. Nothing; the set is for long-term use.

Change the set in about 4 hours. Because both ends of the set are being manipulated with each dose, standards of practice dictate that the set should be changed every 24 hours, so the set should be changed in about 4 hours.It is not necessary to change out the set immediately, but it must be changed before the next 12 to 24 hours.

The nurse is administering a drug to a client through an implanted port. Before giving the medication, what will the nurse do to ensure safety? Administer 5 mL of a heparinized solution. Check for blood return. Flush the port with 10 mL of normal saline. Palpate the port for stability.

Check for blood return. To ensure safety, before a drug is given through an implanted port, the nurse must first check for blood return. If no blood return is observed, the drug should be held until patency is reestablished.If no blood return is observed, the drug should be held until patency is re-established. Ports are flushed with heparin or saline after, rather than before, use. The port is palpated for stability, but this action alone does not ensure the client's safety.

The nurse is documenting peripheral venous catheter insertion for a client. What will the nurse include in the note? (Select all that apply.) Client's name and hospital number Client's response to the insertion Date and time inserted Type and size of device Type of dressing applied Vein used for insertion

Client's response to the insertion Date and time inserted Type and size of device Type of dressing applied Vein used for insertion The client's ability to adapt to interventions, such as IV insertion, should be noted when the intervention is performed. The date and time of the insertion are important data. IV sites need to be routinely monitored and changed at prescribed intervals per facility policy. It is important to note the device used (often the brand name is given), as well as all specifics such as needle or cannula length, gauge, and material (Teflon). It is necessary to describe the dressing applied, and the vein used should be noted.The client's name and hospital number should be on the medical record, but the nurse makes certain that the information is recorded in the correct medical record.

The nurse is checking an IV fluid order and questions accuracy. What nursing action is appropriate? Ask the charge nurse about the order. Contact the prescribing health care provider. Contact the pharmacy for clarification. Start the fluid as ordered.

Contact the prescribing health care provider. First, the nurse will contact the health care provider who ordered the fluids. The nurse is legally and professionally responsible for accuracy and has the duty to verify the order with the health care provider who ordered it.The nurse can consult the charge nurse, but this is not the definitive action that the nurse should take. Contacting the pharmacy is not the best action that the nurse should take. Giving (or starting) the fluid when the order is questionable is not appropriate and could possibly harm the client.

Acute Transfusion Rxns: bacterial

Contaminated blood products w/ gram negative organisms INSIDE bag Low risk, this is why bags can only be hung for 4 hrs S/S: rapid onset, tachycardia, hypotension, chills, fever, shock

Acute Transfusion Rxns: allergic

Correct itching w/ benadryl, but if anaphylaxis happens, stop infusion ASAP Other s/s: bronchospasm, urticaria Onset during or up to 24 hrs after transfusion Give pt w/ allergy history leukocyte-reduced or washed wbcs (no plasma, IgA, or wbcs mean no allergic rxn)

Catheter Embolism

DECREASED BLOOD PRESSURE PAIN ALONG THE VEIN WEAK, RAPID PULSE CYANOSIS OF THE NAIL BEDS LOSS OF CONSCIOUSNESS emergency, apply turniquet above insertion site and call doctor

Documenting Intravenous Therapy

Date & time of insertion Name of RN who inserted Vein/location that was used Type of VAD used & gauge # of attempts & locations of attempts Pt. response Type of dressing applied Type of securement device (if used) Pt. & family education

nurse's responsibility after transfusion

Dispose bag according to agency policies Document: type of product, product number, volume infused, duration, vitals, any adverse rxns

nurse's responsibility during transfusion

During Infusion: Use appropriate filtered tubing Stay w/ pt for 15-30 mins (rxns happen within first 50 mL of blood), start at about 25 mL/hr S/S of rxn: chills, sob, hives, itching, back pain Assess vitals 15 mins after transfusion has started, if no rxn → rate can be inc. 1 unit in 2 hrs (depending on pt cardiac status and hospital policy) Take vitals hourly or hospital policy Blood components w/o rbcs can be infused quicker PRBCs might result in electrolyte imbalances (inc. K+) Don't infuse drugs w/ blood (clots)

The nurse is to administer a unit of whole blood to a postoperative client. What will the nurse do to ensure the safety of the blood transfusion? Ask the client to both say and spell his or her full name before starting the blood transfusion. Ensure that another qualified health care professional checks the unit before administering. Check the blood identification numbers with the laboratory technician at the blood bank at the time it is dispensed. Make certain that an IV solution of 0.9% normal saline is infusing into the client before starting the unit.

Ensure that another qualified health care professional checks the unit before administering. To ensure safety, blood must be checked by two qualified health care professionals, usually two registered nurses.Administering an incorrectly matched unit of blood creates great consequences for the client and is considered to be a sentinel event. It requires a great amount of follow-up and often changing of policies to improve safety. The Joint Commission requires that the client provide two identifiers, but they are the name and date of birth or some other identifying data, depending on the facility; saying and spelling the name is only one identifier. Although a check is provided at the blood bank, this is not the one that is done before administration to the client. Clients do need to have normal saline running with blood, but this is not considered to be part of the safety check before administration of blood and blood products.

A male client is seen in the emergency department (ED) with pain, redness, and warmth of the right lower arm. The client was in the ED last week after an accident at work where he received 12 hours of IV fluids. On assessment, the nurse notes the presence of a palpable cord 1 inch (2.5 cm) in length and streak formation. How will the nurse document the assessment? Grade 1 phlebitis Grade 2 phlebitis Grade 3 phlebitis Grade 4 phlebitis

Grade 3 phlebitis Grade 3 phlebitis indicates pain at the access site with erythema and/or edema and streak formation with a 1' palpable cord.Grade 1 indicates only erythema with or without pain; the client has additional symptoms. Grade 2 indicates only pain at the access site with erythema and/or edema; the client has additional symptoms. Grade 4 indicates pain at the access site with erythema and/or edema, streak formation, a palpable venous cord longer than 1 inch (2.5 cm), and purulent drainage. No purulent drainage is present in this client, and the palpable cord is 1 inch (2.5 cm) in length.

HANDS Mnemonic

H: Hygiene—Wash your hands and use gloves before inserting a peripheral catheter or drawing blood. Ensure that skin is clean. If visibly soiled, cleanse with soap and water. A: Antisepsis—Prepare clean skin with a skin antiseptic (chlorhexidine 2% with 70% alcohol, 70% isopropyl alcohol, or povidone-iodine) with a back-and-forth motion for 30 seconds and allow the solution to dry before peripheral venous catheter insertion. N: No-Touch Technique—Once the area has been prepped, do not touch the site. D: Documentation—Document assessment of the site, dressing, and tubing. Ensure that the date is clear for all infusion sites. S: Scrub the Hub—Scrub the hub of the catheter site with an alcohol pad for at least 15 seconds each time you access an infusion site.

22 gauge

Indications: Adequate for most therapies; blood can infuse without damage Approximate Flow Rates: 38 mL/min (2280 mL/hr)

14-16 gauge

Indications: For trauma and surgical patients requiring rapid fluid resuscitation Needs to be in a vein that can accommodate Approximate Flow Rates: Over 200 mL/min (12,000 mL/hr)

18 gauge

Indications: Preferred size for surgery Vein needs to be large enough to accommodate the catheter Approximate Flow Rates: 110 mL/min (6600 mL/hr)

A client who takes corticosteroids daily for rheumatoid arthritis requires insertion of an IV catheter to receive IV antibiotics for 5 days. Which type of IV catheter does the charge nurse teach the new nurse to use for this client? Midline catheter Tunneled percutaneous central catheter Peripherally inserted central catheter Short peripheral catheter

Midline catheter For a client with fragile veins (which occur with long-term corticosteroid use) and the need for a catheter for 5 days, the midline catheter is the best choice.Tunneled central catheters usually are used for clients who require IV access for longer periods. Peripherally inserted central catheters usually are used for clients who require IV access for longer periods. A short peripheral catheter is likely to infiltrate before 5 days in a client with fragile veins, requiring reinsertion.

nurse's responsibility before transfusion

Need prescription from primary healthcare provider with: type of component, volume (dose), duration of transfusion any special conditions (sometimes need a consent form) Assess lab values (HgB and HcT) Take vitals, urine output, hx of transfusion rxns, skin color Need another rn to verify name, blood compatibility, expiration time Use NS, not LR or dextrose Ensure ABO and Rh types are compatible on blood bag, and expiration date, discoloration, bubbles, cloudiness Make sure pt name and number correspond to blood bag Use minimum 22-gauge needle Blood specimen test for type and crossmatch needed Q72 hrs

Acute Transfusion Rxns: hemolytic

Rbc destroyed due to inflammatory response on blood vessels/walls caused by blood type or Rh-incompatibility Even 10 mL can kill pt, life threatening s/s: disseminated intravascular coagulation and circulatory collapse s/s: fever, chills, apprehension, headache, chest pain, low back pain, tachycardia/pnea, hemoglobinuria, hypotension, impending doom May not immediately have a rxn

The nurse is revising an agency's recommended central line-associated bloodstream infection (CLABSI) bundle. Which actions decrease the client's risk for this complication? (Select all that apply.) During insertion, draping just the area around the site with a sterile barrier Removing the client's venous access device (VAD) when it is no longer needed Making certain that observers of the insertion are instructed to look away during the procedure Thorough hand hygiene before insertion Using chlorhexidine for skin disinfection

Removing the client's venous access device (VAD) when it is no longer needed Thorough hand hygiene before insertion Using chlorhexidine for skin disinfection As soon as the VAD is deemed unnecessary, it needs to be removed to reduce the risk for infection. Thorough handwashing is a key factor in insertion and maintenance of a central line device. Quick handwashing is not sufficient. Chlorhexidine is recommended for skin disinfection because it has been shown to have the best outcomes in infection prevention.During the insertion, the whole body (head to toe) of the client is draped with a sterile barrier. Draping only the area around the site will increase risk for infection. Looking away will not reduce the risk for infection. Reducing the number of people in the room and having everyone wear a mask will help reduce the risk for infection.

The nurse is preparing to insert a peripheral venous catheter. What action will the nurse take? Palpate for hardness of a vein. Use the client's dominant arm for insertion. Select the most distal site. Look near the elbow joint first.

Select the most distal site. The nurse will choose the most distal site and make all subsequent venipunctures proximal to previous sites. The nurse will not palpate for hard or cordlike veins as these are not ideal for cannulation. The nurse will use the client's nondominant arm and avoid areas of joint flexion.

An older adult client receiving an infusion of 5% dextrose in 0.9% normal saline at 150 mL/hour has developed shortness of breath with a decrease in oxygen saturation to 86%. What is the priority nursing intervention? Notify the health care provider Place the client on oxygen Sit the client upright in bed Assess the client's lung sounds

Sit the client upright in bed Because the client is short of breath, the priority action that can be done immediately is to sit the client upright in bed. Assessing the lung sounds can occur after sitting the client upright. Use of oxygen and contacting the healthcare provider will follow the priority action. The rate of infusion is likely too fast for an older adult client which has created fluid build-up. The nurse will anticipate fine crackles in the lung bases and decrease in the IV flow rate and notify the health care provider.

The nurse is teaching a course about the special needs of older adults receiving IV therapy. What teaching will the nurse include? Placement of the catheter on the back of the client's dominant hand is preferred. Skin integrity can be compromised easily by the application of tape or dressings. To avoid rolling the veins, a greater angle of 25 degrees between the skin and the catheter improves success with venipuncture. When the catheter is inserted into the forearm, excess hair should be shaved before insertion.

Skin integrity can be compromised easily by the application of tape or dressings. Skin in older adults tends to be thin. Tape or dressings used with IV therapy can compromise skin integrity.Placement on the back of the dominant hand is contraindicated because hand movement can increase the risk of catheter dislodgement. An angle smaller than 25 degrees is required for venipuncture success in older adults. This technique is less likely to puncture through the older adult client's vein. Clipping, and not shaving, the hair around the insertion site typically is necessary only for younger men.

24-26 gauge

Smallest, shortest (¾-inch length) Indications: Not ideal for viscous infusions Expect blood transfusion to take longer Preferred for infants and small children Approximate Flow Rates: 24 mL/min (1440 mL/hr)

When flushing a client's central line with normal saline, the nurse feels resistance. Which action will the nurse take first? Decrease the pressure being used to flush the line. Obtain a 10-mL syringe and reattempt flushing the line. Stop flushing and try to aspirate blood from the line. Use "push-pull" pressure applied to the syringe while flushing the line.

Stop flushing and try to aspirate blood from the line. The nurse's first step is to stop flushing and try to aspirate blood from the line. If resistance is felt when flushing any IV line, the nurse should stop and further assess the line. Aspiration of blood would indicate that the central line is intact and is not obstructed by thrombus.Decreasing the pressure to flush the line is not appropriate. Continuing or reattempting to flush the line, or using a push-pull action on the syringe, might result in thrombus or injection of particulate matter into the client's circulation.

A client receiving gentamycin intravenously reports that the peripheral IV insertion site has become painful and reddened. What is the priority nursing action? Contact the primary health care provider. Document findings in the electronic health record. Change the IV site to a new location. Stop the infusion of the drug.

Stop the infusion of the drug. The nurse needs to stop the infusion of the drug first because the IV site is likely infiltrated. Then documentation, notifying the primary health care provider, and starting a new IV can occur.

What purpose does the use midline catheters serve? And what safety precautions are there to keep in mind?

TPN (bypasses GI) peripheral IV, goes in antecubital or basilic, confirm placement with xray, sutured in place if using double lumen do not administer incompatable drugs simultaneously used when skin integrity or limited peripheral veins make it difficult to maintain an SPC, reduces the amount of repeated IV cannulations fluids for hydration or drug therapy for 6-14 days, rapid infusion strict sterile technique for insertion and dressing change nurses need extra education and skill assessment fluids and meds must be b/n 5-9, fluid <600 mOsm/L no blood drawing from this routinely no vesicants do not place in extremities of mastectomy w/ lymphedema, dialysis grafts/fistulas, or paralysis

What complications may arise in non-tunneled Percutaneous Central Venous Catheters

The presence of a tracheotomy increases the risk for cross-contamination of the insertion site The warmer, moister skin of the neck and upper chest has more types and higher numbers of microorganisms, resulting in more CRBSIs with this type of catheter. patient must be placed in the Trendelenburg position, usually with a rolled towel between the shoulder blades position may be difficult or contraindicated for patients with respiratory conditions, spinal curvatures, and increased intracranial pressure, especially for older adults

Which nursing assessment data indicate the need for immediate nursing intervention? Client states, "It really hurt when the nurse put the IV in." The vein feels hard and cordlike above the insertion site. Transparent dressing was changed 5 days ago. Tubing for the IV was last changed 72 hours ago.

The vein feels hard and cordlike above the insertion site. A hard, cordlike vein suggests phlebitis at the IV site and indicates an immediate need for nursing intervention. The IV should be discontinued and restarted at another site.It is common for IVs to cause pain during insertion. An intact transparent dressing requires changing only every 7 days. Tubing for peripheral IVs should be changed every 72 to 96 hours.

Acute Transfusion Rxns: TACO

Transfusion-associated circulatory overload (TACO): Blood products infused too quickly In older pts and those w/ heart issues, in whole-blood or multiple-packed rbc transfusions Give pt lasix to avoid this S/S: HTN, bounding pulse, distended neck veins, dyspnea, restlessness, confusion

Acute Transfusion Rxns: TV-GHD

Transfusion-associated graft vs host disease (TA-GVHD): Rare, happens in immunocompromised pts Allogeneic stem cell transplantation, donor-T cells attack host tissues S/S: 1-2 weeks, thrombocytopenia, anorexia, nausea, vomiting, chronic hepatitis, weight loss, recurrent infections Prevent by using irradiated blood products

speed shock

caused by rush of IV fluid administered; med races to blood-rich heart and brain and floods them w/toxic levels of med

3 systemic complications during infusion

circulatory overload, speed shock, catheter embolism

How often you change IV tubing: blood

continuous is 4 hrs intermittent- if one unit is used, discard it after flushing it

How often you change IV tubing: primary

continuous is 72-96 hrs intermittent is 24 hrs

If any of these symptoms are present: infiltration, including swelling, coolness, tingling, or redness. You should

discontinue the drug immediately and notify the infusion therapy team, if available. If an infusion specialist is not available, remove the IV catheter and notify the primary health care provider.

Non-tunneled is used for what?

emergent, trauma, critical care, surgery (preferred for short term care, not at home care)

The Joint Commission NPSGs require that all patients who have central venous catheters placed must

have education on prevention of catheter-related bloodstream infection

PICC line- troubleshooting if you cannot get fluids in and out

have pt cough or lift arm above head, do not push or pull any harder if the line isn't patent

Local complications during infusion

infiltration, extravasation, phlebitis, thrombosis, ecchymosis

The INS recommends that PICC lines not actively in use be flushed with heparin at least daily when using a _______________ and at least weekly with a ______________.

nonvalved catheter valved catheter

Dialysis catheter safety and when you cannot use it

only trained dialysis nurses can touch this don't take bp on side w/ renal failure emergency use only, CRBSI risk not for administration of fluid or drugs

Pt education for PICC

prevention of bloodstream infection: hand hygiene, aseptic technique, everyone must wear a mask in the room upon insertion, measure upper arm circumference as a baseline, daily review of line necessity w/ prompt removal of unnecessary lines, use chlorhexidine on skin, optimal catheter site selection and postplacement care with avoidance of the femoral vein for central venous access in adult patients, maximal barrier precautions on insertion, put sign on the door while replacing catheter can do ADLs but avoid heavy lifting (paraplegics or people on crutches cannot have this inserted)

Acute Transfusion Rxns: febrile

pts w/ anti-wbc antibodies, can develop after multiple transfusions/WBC transfusions/platelet transfusions s/s: chills, fever (temp inc. by 2º), tachycardia/pnea, hypotension Reduce chance of this by given leukocyte-reduced blood or single-donor HLA-matched platelets Correct large fever w/ small fluid bolus and tylenol

Extravasation results in

severe tissue integrity impairment as manifested by blistering, tissue sloughing, or necrosis from infiltration into the surrounding tissues.

Implanted ports

venous access device huber needle: Before giving a drug through an implanted port, always check for blood return. INS defines blood return "as the color and consistency of whole blood upon aspiration." If there is no blood return, withhold the drug until patency and adequate noncoring needle placement of the port are established. Serious extravasations of vesicant drugs can occur because a fibrin sheath (flap or tail) may occur at the tip of the catheter, clot it, and cause retrograde subcutaneous leakage. port is surgically implanted replace yearly flush w/ heparin

Drugs with vasoconstrictive action (e.g., dopamine or chemotherapeutic agents) are

vesicants (chemicals that damage body tissue on direct contact) that can cause extravasation.

Removing access device:

when it's no longer needed, having to flush/no longer patent (for VAD: as soon as one lumen isn't patent), a break of the integrity of the device is noted (notify primary healthcare provider removal is needed), remove all IVs prior to discharge, local/systemic complications, barrier b/n skin and tourniquet, paper tape on fragile skin, lightly tap before removal, force blood into veins by opening and closing fists, apply warm compress, have blood drain to heart

Before giving a drug through an implanted port, always check for blood return (color and consistency of whole blood upon aspiration). If there is no blood return,

withhold the drug until patency and adequate noncoring needle placement of the port are established. Serious extravasations of vesicant drugs can occur because a fibrin sheath (flap or tail) may occur at the tip of the catheter, clot it, and cause retrograde subcutaneous leakage.

The Older Adult Receiving a Transfusion

• Assess the patient's circulatory, kidney, and fluid status before starting the transfusion. • Use no larger than a 19-gauge needle. • Try to use blood that is less than 1 week old. (Older blood cell membranes are more fragile, break easily, and release potassium into the circulation.) • Take vital signs (especially pulse, blood pressure, and respiratory rate) every 15 minutes throughout the transfusion. Changes in these parameters can indicate fluid overload and may also be the only indicators of adverse transfusion reactions: • Rapid bounding pulse • Hypertension • Swollen superficial veins • Transfusion reaction: • Hypotension • Rapid thready pulse • Increased pallor, cyanosis • Infuse blood slowly, taking 2 to 4 hours for each unit of whole blood, packed red blood cells, or plasma. • Avoid concurrent fluid administration into any other IV site. • If possible, allow 2 full hours after infusing 1 unit of blood before infusing the next unit.

Placement of Short Peripheral Venous Catheters

• Verify that the prescription for infusion therapy is complete and appropriate for infusion through a short peripheral catheter. • For adults, choose a site for placement in the upper extremity. DO NOT USE THE WRIST. • Choose the patient's nondominant arm when possible. • Choose a distal site and make all subsequent venipunctures proximal to previous sites. • Do not use the arm on the side of a mastectomy, lymph node dissection, arteriovenous shunt or fistula, or paralysis. • Avoid choosing a site in an area of joint flexion. • Avoid choosing a site in a vein that feels hard or cordlike. • Avoid choosing a site close to areas of cellulitis, dermatitis, or complications from previous catheter sites. • Choose a vein of appropriate length and width to fit the size of the catheter required for infusion. • Limit unsuccessful attempts to two per clinician and no more than four total