CHAP 18 FLUIDS AND ELECTROLYTES made up IV therapy

which complication does the nurse know that an older adult patient is at greater risk for when receiving IV therapy?

Infiltration

The nurse is assessing the IV site. If redness, swelling and warmth are noted, what is the likely cause? 1. Infiltration and air embolus 2. Inflammation and possible phlebitis 3. Blood loss and hemorrhage 4. Embolus from the former catheter

Inflammation and possible phlebitis

Which nursing intervention is the most important in preventing the introduction of microorganisms to the patient when an IV infusion is initiated? 1. Hand hygiene 2. Checking the identification of the patient 3. Ensuring the six rights of medication administration 4. Carefully checking the order for the correct IV solution

Hand hygiene

A patient's IV has infiltrated. When selecting a site for a new IV line the nurse should perform which action? 1. Choose an area proximal to the current site. 2. Look for hard, cordlike veins. 3. Use sites distal from the current site. 4. Select the patient's dominant arm.

Use sites distal from the current site.

for which length of time would the LPN expect the RN to stay with the patient to monitor vitals and watch for reaction if the patient is receiving blood?

first 15 to 20 minutes

which action would the PCP follow while inserting a tunneled CVAD in a patient who is in a coma?

insert the device through the subclavian vein and into the superior vena cava.

which nursing intervention, if implemented, could increase the patients risk for injury related to a transfusion of a unit of blood for hypovolemic shock? (select all that apply)

lactated ringers solution normal saline w/ 5% dextrose is used during the infusion.

which action if taken by the new nurse graduate, would place the patient at risk during the insertion of a peripheral IV line?

placing the IV in the arm on the side of a mastectomy

which solution is the only one to be used with a blood transfusion?

0.9% sodium chloride/ normal saline

Which needle gauge would be needed for a rapid transfusion of whole blood? 1. 14- to 16-gauge 2. 18- to 22-gauge 3. 22- to 24-gauge 4. 26- to 28-gauge

14- to 16-gauge

which catheter would be best for the LPN to use when inserting an IV line in a patient who needs an IV line for a blood transfusion?

18 gauge

which length of time, as a minimum, would the nurse hold pressure after removal of an IV line catheter if a patient is being discharged home?

2-3 minutes

The normal pH of blood is approximately

7.35-7.45

The nurse is checking IV sites carefully for signs of infiltration. Which symptoms indicate infiltration at the IV site? 1. Burning sensation, pain, and puffiness at the site 2. Pain, heat, and puffiness at the site 3. Burning sensation and numbness at the site 3. Red streak up the arm

Burning sensation, pain, puffiness at the site

An older adult patient is evaluated by the nurse for signs of fluid volume excess in association with IV therapy. Which symptom would indicate fluid volume excess in an elderly patient? 1. Redness, warmth, and drainage of fluid at the IV site 2. Redness, warmth, and tenderness at the IV site 3. Complaints of shortness of breath and pounding pulse 4. Puffiness of face, dyspnea, and pain at the IV site

Complaints of shortness of breath and pounding pulse

which step would be taken next by the nurse after stopping a blood transfusion in a patient with suspected infusion reaction?

KVO with normal saline 0.9%

The nurse is assisting to prepare a nursing care plan for a patient with continuous IV infusions. What is the goal of IV therapy? 1. Promote and maintain fluid and electrolyte balance 2. Promote drug blood levels when the patient is able to take liquid medication by mouth 3. Promote oxygen and carbon dioxide homeostasis 4. Balance plasma acidity levels

Promote and maintain fluid and electrolyte balance

A patient complains of a headache, nausea, and vomiting during a blood transfusion. Which action is necessary for the nurse to take immediately? 1. Check the vital signs. 2. Stop the blood transfusion. 3. Slow down the rate of blood flow. 4. Notify the health care provider and the blood bank personnel.

Stop the blood transfusion

It has been 15 minutes since a blood infusion was initiated. What is most indicative that the patient is experiencing a blood transfusion reaction? 1. The patient's blood pressure decreases 2. The patient feels an urgent need to void 3. The patient's skin is pale at the infusion site 4. Localized edema is noticed at the infusion site.

The patient's blood pressure decreases

which complication is most likely to happen in a patient on IV therapy who reports pain and swelling at the IV site?

Thrombolites

A central line is preferred over peripheral IV line under which conditions? (Select that all apply) 1. ? When irritating IV fluids are given 2. In an infant 3. When short-term IV therapy is required 4. ? When the patient has poor peripheral veins 5. ? When the patient is to receive chemotherapy

When irritating IV fluids are given When the patient has poor peripheral veins When the patient is to receive chemotherapy

which action in oncology would the nurse take if the nurse recieves an order for IV therapy and is twice unsuccessful?

ask another nurse for assistance starting the IV line