Chapter 13

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13. The nurse finishes administering an intermittent medication through a Groshong catheter. What is the nurses next action? a. Clamping the catheter b. Flushing the line with saline c. Flushing with heparin d. Removing the access needle

ANS: B The Groshong catheter is a type of midline catheter. After intermittent use, the catheter is to be flushed with saline. The manufacturers instructions state that the catheter should not be clamped to maintain the integrity of the catheter valve. If a heparin flush is ordered, it is given after the catheter has been flushed with saline. The access needle is used for implanted ports. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation)

18. A nurse is preparing to administer a blood transfusion. What action is most important? a. Correctly identifying client using two identifiers b. Ensuring informed consent is obtained if required c. Hanging the blood product with Ringers lactate d. Staying 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. Ringers lactate is not used to transfuse blood. The nurse does not need to stay with the client for the duration of the transfusion

22. A nurse is changing the administration set on a clients central venous catheter. Which intervention is most important for the nurse to complete? a. Have the client hold his breath during the set change. b. Keep the slide clamp on the catheter extension open. c. Position the client in a high Fowlers position. d. Position in the client in a semi-Fowlers position.

ANS: A An air embolus is less likely to form if the exit site is lower than the level of the heart, and if pressure in the thoracic cavity is greater when the disconnection occurs. Having the client perform the Valsalva maneuver and maintain it during disconnection and reconnection helps maintain higher intrathoracic pressure. The slide clamp on the catheter extension should be kept clamped. The client should be placed in the flat position when administration sets are changed. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation)

15.A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client? a. Allergic reaction b. Bowel obstruction c. Catheter lumen occlusion d. Infection

ANS: D Fever, abdominal pain, abdominal rigidity, and rebound tenderness may be present in the client who has peritonitis related to intraperitoneal therapy. Peritonitis is preventable by using strict aseptic technique in handling all equipment and infusion supplies. An allergic reaction would occur earlier in the course of treatment. Bowel obstruction and catheter lumen occlusion can occur but would present clinically in different ways. DIF:Applying/ApplicationREF:206 KEY:Vascular access device| infection MSC:Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

11.A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the clients 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 clients skin, the nurse should place a washcloth or the clients gown between the skin and tourniquet. The other interventions are methods to distend the vein but will not protect the clients skin. DIF:Understanding/ComprehensionREF:209 KEY:Vascular access device| older adult MSC:Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2.A client is prescribed 250 mL of normal saline to infuse over 4 hours via gravity. The facility supplies gravity tubing with a drip factor of 15 drops/mL. At what rate (drops/min) should the nurse set the infusion to deliver? (Record your answer using a whole number.) _____ drops/min

ANS: 16 drops/min DIF: Applying/Application REF: 193 KEY: Medication safety MSC:Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

17.A nurse prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of heparin. The pharmacy supplies a multi-dose vial of heparin with a concentration of 100 units/mL. Which of the syringes shown below should the nurse use to draw up and administer the heparin? a. 20 ml b. 5 ml c. 3 ml d. 10 ml

ANS: D Always use a 10-mL syringe when flushing PICC lines because a smaller syringe creates higher pressure, which could rupture the lumen of the PICC. DIF:Applying/ApplicationREF:194 KEY:Medication safety| vascular access device MSC:Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

27. Which instruction is the most accurate for the nurse to give a client who has a patient-controlled analgesia device (PCA) after abdominal surgery? a. Instruct your visitors to press the button for you when you are sleeping. b. Push the button every 15 minutes whether you feel pain at that time or not. c. Push the button when you first feel pain instead of waiting until pain is severe. d. Try to go as long as you possibly can before you press the button.

ANS: C Clients should be instructed to push the button to release medication when the pain begins rather than waiting until the pain becomes so great that the dose given by the pump cannot control the pain. No one should push the button for the client. Clients should not be instructed to bear the pain as long as possible before using PCA. DIF: Cognitive Level: Comprehension/Understanding REF: p. 54 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesPharmacological Pain Management) MSC: Integrated Process: Teaching/Learning

2.A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first? a. Amount of pressure in fluid container b. Date of catheter tubing change c. Percent of heparin in infusion container d. Presence of an ulnar pulse

ANS: D An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased perfusion to the extremity. Assessment of an ulnar pulse is one way to assess circulation to the arm in which the catheter is located. 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. Because of heparin-induced thrombocytopenia, heparin is not used in most institutions for an arterial catheter. DIF:Applying/ApplicationREF:212 KEY:Vascular access device MSC:Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

28. Which client is the best candidate to receive hypodermoclysis for IV therapy? a. Client requiring 4000 mL normal saline in 24 hours b. Client with an extensive burn injury c. Client with allergy to hyaluronidase d. Client receiving pain management

ANS: D Subcutaneous therapy (hypodermoclysis) involves the slow infusion of isotonic fluids into the clients subcutaneous tissue. Most often, it is used in hospices for pain management. It should not be used if fluid replacement needs exceed 3000 mL/day. To be used, the client must have sufficient areas of intact skin. Hyaluronidase is frequently used to help absorb the fluid during therapy. DIF: Cognitive Level: Comprehension/Understanding REF: p. 234 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapyParenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Assessment)

SHORT ANSWER 1.A client is prescribed 1000 mL of normal saline to infuse over 24 hours. At what rate should the nurse set the pump (mL/hr) to deliver this infusion? (Record your answer using a whole number.) ____ mL/hr

ANS:42 1000 mL 24 hours = 41.6 mL/hr. DIF: Applying/Application REF: 193 KEY: Medication safety MSC:Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

2. The nurse is preparing to administer a medication IV push. What information does the nurse need to know before beginning the infusion? (Select all that apply.) a. Any dilution required b. Rate of administration c. Compatibility with infusions d. Other routes of administration e. Specific monitoring needed

ANS: A, B, C, E Giving IV push medications requires specific knowledge about each drug, including dilution, rate of administration, compatibility, and monitoring. pH and osmolarity and specific infusion sites appropriate for giving the specific drug are also important to know. When giving an IV push medication, it is not necessary to know whether other routes of administration are possible. DIF: Cognitive Level: Comprehension/Understanding REF: p. 212 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)

12. A nurse on the postoperative inpatient unit receives a hand-off report on four clients using patient-controlled analgesia (PCA) pumps. Which client should the nurse see first? a. Client who appears to be sleeping soundly b. Client with no bolus request in 6 hours c. Client who is pressing the button every 10 minutes d. Client with a respiratory rate of 8 breaths/mi

ANS: D Continuous delivery of opioid analgesia can lead to respiratory depression and extreme sedation. A respiratory rate of 8 breaths/min is below normal, so the nurse should first check this client. The client sleeping soundly could either be overly sedated or just comfortable and should be checked next. Pressing the button every 10 minutes indicates the client has a high level of pain, but the device has a lockout determining how often a bolus can be delivered. Therefore, the client cannot overdose. The nurse should next assess that clients pain. The client who has not needed a bolus of pain medicine in several hours has well-controlled pain.

3. Which infusion device does the nurse select for the older adult client with a medical diagnosis of dehydration? a. Cassette pump b. Elastomeric balloons c. Volumetric controller d. Syringe pump

ANS: A An older adult client who has dehydration will require a large fluid volume that is accurately measured by using a cassette pump during the infusion. Volumetric controllers count drops for administered volume and are inherently inaccurate because of variation in drop size. A syringe pump is accurate but not appropriate for a large volume. Elastomeric balloons are used to deliver intermittent medications. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlError Prevention) MSC: Integrated Process: Nursing Process (Implementation)

35. A nurse is preparing to administer two drugs at the same time to a client via a double-lumen midline catheter. Which action by the nurse is most important? a. Check the two drugs for compatibility. b. Compare the recommended infusion times. c. Schedule any post-infusion lab draws. d. Flush both lumens with saline before starting the infusion.

ANS: A Because midline catheters dwell in the peripheral, not central, circulation, incompatible drugs should not be given together via a double-lumen midline catheter because the flow rate of the blood is not high enough to dilute the drugs before they mix. The other options are valid interventions before starting the infusion, but they do not take precedence over determining whether the drugs may be infused at the same time. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapyParenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation)

25. The nurse is caring for a client who is receiving an epidural infusion for pain management. Which action has the highest priority? a. Assessing the respiratory rate b. Changing the dressing over the site c. Using various pain management therapies d. Weaning the pain medication

ANS: A Complications from an epidural infusion can be caused by the type of medication being infused, or they can be related to the catheter. When used for pain management, the client needs to be assessed for level of alertness, respiratory status, and itching. Dressings are not routinely changed because the catheter is used for only short periods. Using other pain management therapies and weaning the pain medication are important, but monitoring respiratory status has the highest priority in the nursing care of this client. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Implementation)

16. When an IV pump alarms because of pressure, what action does the nurse take first? a. Check for kinking of the catheter. b. Flush the catheter with a thrombolytic enzyme. c. Get a new infusion pump. d. Remove the IV catheter.

ANS: A Fluid flow through the infusion system requires that pressure on the external side be greater than pressure at the catheter tip. Fluid flow can be slowed for many reasons. A common reason, and one that is easy to correct, is a kinked catheter. If this is not the cause of the pressure alarm, the nurse may have to ascertain whether a clot has formed inside the catheter lumen, or if the pump is no longer functional. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation)

10.A nurse responds to an IV pump alarm related to increased pressure. Which action should the nurse take first? a. Check for kinking of the catheter. b. Flush the catheter with a thrombolytic enzyme. c. Get a new infusion pump. d. Remove the IV catheter.

ANS: A Fluid flow through the infusion system requires that pressure on the external side be greater than pressure at the catheter tip. Fluid flow can be slowed for many reasons. A common reason, and one that is easy to correct, is a kinked catheter. If this is not the cause of the pressure alarm, the nurse may have to ascertain whether a clot has formed inside the catheter lumen, or if the pump is no longer functional. Removal of the IV catheter and placement of a new IV catheter should be completed when no other option has resolved the problem. DIF:Applying/ApplicationREF:202 KEY:Medication safety| vascular access device MSC:Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

34. A nursing student asks why midline catheters need strict sterile dressing changes when short peripheral IVs do not. Which answer by the experienced nurse is most accurate? a. Because of the length of time they stay inserted. b. They really dont need strict sterile technique. c. Because the tip is in the right atrium of the heart. d. The tonicity of the fluids used promotes infection.

ANS: A Midline catheters can stay in place for as long as 4 weeks, so dressing changes must be done with strict sterile technique to reduce the incidence of infection. The tip does not lie in the right atrium it resides no farther than the axillary vein. These catheters are used for a wide range of fluids and medications, so tonicity would not be a factor in infection risk. DIF: Cognitive Level: Comprehension/Understanding REF: p. 216 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapyParenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation)

4. A nursing administrator is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which action by the administrator would have the biggest impact on decreasing complications? a. Investigate initiating a dedicated IV team. b. Require inservice education for all RNs. c. Limit IV starts to the most experienced nurses. d. Perform quality control testing on skin preparation products.

ANS: A The Centers for Disease Control and Prevention (CDC) recommends having a dedicated IV team to reduce complications, save money, and improve client satisfaction and outcomes. In-service education would always be helpful, but it would not have the same outcomes as an IV team. Limiting IV starts to the most experienced nurses does not allow newer nurses to gain this expertise. The quality of skin preparation products is only one aspect of IV insertion that could contribute to infection. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Implementation)

16.A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should the nurse suggest to the management team to make the biggest impact on decreasing complications? a. Initiate a dedicated team to insert access devices. b. Require additional education for all nurses. c. Limit the use of peripheral venous access devices. d. Perform quality control testing on skin preparation products.

ANS: A The Centers for Disease Control and Prevention recommends having a dedicated IV team to reduce complications, save money, and improve client satisfaction and outcomes. In-service education would always be helpful, but it would not have the same outcomes as an IV team. Limiting IV starts to the most experienced nurses does not allow newer nurses to gain this expertise. The quality of skin preparation products is only one aspect of IV insertion that could contribute to infection. DIF:Applying/ApplicationREF:187 KEY: Vascular access device| infection| quality improvement| core measure MSC:Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

12. To prevent infection when infusing an intermittent piggyback line, which intervention does the nurse implement? a. Backpriming the secondary container from the primary line b. Detaching and capping the secondary line after use c. Using a new secondary container with each drug infused d. Using sterile gloves when administering medication

ANS: A The backpriming method allows multiple drugs to be infused through the same secondary set. This method allows the primary and secondary sets to remain connected together as an infusion system and allows the nurse to adhere to the Infusion Nurses Society (INS) standards of practice. The client is at increased risk for infection whenever the catheter is disconnected from the tubing. Sterile gloves are not necessary for IV administration of medication. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation)

24. What action does the nurse take to prevent infection in the older adult receiving IV therapy? a. Applying skin protectant before applying the dressing b. Avoiding the use of alcohol pads when removing tape c. Shaving the skin before attempting the venipuncture d. Using maximum friction to cleanse the skin

ANS: A The skin of an older adult may be more delicate and compromised. Avoidance of a disruption in skin integrity lessens the chance of an infection occurring with an IV catheter. A barrier applied to the skin before the IV dressing is placed helps maintain skin integrity. Using alcohol pads makes it easier to remove tape and avoid skin tears. The skin should never be shaved before venipuncture because micro-abrasions may occur, and these can lead to infection. Excessive friction may damage fragile skin and compromise skin integrity. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation)

40. The nurse preparing to insert an IV on an older adult client notices that the clients skin is extremely fragile. Which action by the nurse is best? a. Use a blood pressure cuff to cause the vein to distend. b. Slap the skin vigorously to cause the vein to rise. c. Place a gauze pad under the tourniquet before tightening. d. Avoid the use of a tourniquet if the vein is already hard.

ANS: A The skin of older adults is often fragile, and a tourniquet may leave an ecchymotic area after the IV insertion. One option for fragile skin is to inflate a blood pressure cuff to a reading just slightly less than the clients diastolic pressure. Tapping the skin lightly may help distend a vein, but avoid slapping vigorously. Gauze padding would not prevent bruising. Veins that are already distended may be cannulated without using a tourniquet, but they must be assessed first, and hard or cordlike veins need to be avoided. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapyParenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation)

MULTIPLE RESPONSE 1. The RN is working with an experienced LPN (licensed practical nurse) who has been assigned several clients receiving IV therapy. What actions guide the RN in delegating aspects of IV therapy to the LPN? (Select all that apply.) a. Look up and read the State Nurse Practice Act. b. Check facility policy regarding LPNs and IV therapy. c. Ask the LPN what he or she is comfortable performing. d. Supervise the LPN when performing IV therapy. e. Divide the clients up between the two of them.

ANS: A, B The State Nurse Practice Act will have the information the RN needs, and in some states, LPNs are able to perform specific aspects of IV therapy. However, in a client care situation, it may be difficult and time-consuming to find it and read what LPNs are permitted to do, so another good solution would be for the nurse to check facility policy and follow it. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareDelegation)

4. The nurse is preparing to give a client an IV push medication through an intermittent IV set (saline lock) using a needleless system. Which actions by the nurse are most appropriate? (Select all that apply.) a. Cleanse the access port vigorously for at least 30 seconds. b. Use an antimicrobial agent when cleansing the port. c. Clean the ridges in the Luer-Lok connection well. d. Rinse the antimicrobial agent off with saline. e. Allow the antimicrobial agent to dry before using IV.

ANS: A, B, C Needleless systems need careful cleansing before use. Guidelines include scrubbing the connection vigorously with an antimicrobial agent for 30 seconds, and paying special attention to the ridges in the Luer-Lok device. Rinsing and drying are not necessary. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Diagnostic Tests/Treatments/Procedures)

18.A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the clients chart prior to administering the medication: Client: Thomas Jackson DOB: 5/3/1936 Gender: Male January 23 (Today): Right upper extremity PICC is intact, patent, and has a good blood return. Site clean and free from manifestations of infiltration, irritation, and infection. Sue Franks, RN January 20: Purulent drainage from sacral wound. Wound cleansed and dressing changed. Dr. Smith notified and updated on client status. New orders received for intravenous antibiotics. Sue Franks, RN January 13: Client alert and oriented. Sacral wound dressing changed. Sue Franks, RN January 6: Right upper extremity PICC inserted. No complications. Discharged with home health care. Dr. Smith Based on the information provided, which action should the nurse take? a. Notify the health care provider. b. Administer the prescribed medication. c. Discontinue the PICC. d. Switch the medication to the oral route.

ANS: B A PICC that is functioning well without inflammation or infection may remain in place for months or even years. Because the line shows no signs of complications, it is permissible to administer the IV antibiotic. There is no need to call the physician to have the IV route changed to an oral route. DIF:Applying/ApplicationREF:194 KEY:Medication safety| vascular access device MSC:Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

36. A client has just had a central venous access line inserted. What is the nurses next action? a. Beginning the prescribed infusion as soon as possible b. Confirming placement of the catheter by x-ray c. Having the infusion team start the IV therapy d. Confirming that solutions are appropriate for the 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlSafe Use of Equipment) MSC: Integrated Process: Nursing Process (Implementation)

MULTIPLE CHOICE 1.A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next? a. Begin the prescribed infusion via the new access. b. Ensure an x-ray is completed to confirm placement. c. Check medication calculations with a second RN. d. Make sure 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. DIF:Applying/ApplicationREF:193 KEY:Vascular access device MSC:Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

18. A client who is having a tunneled central venous catheter inserted begins to report chest pain and difficulty breathing. What action does the nurse take first? a. Administer the PRN pain medication. b. Prepare to assist with chest tube insertion. c. Place a sterile dressing over the IV site. d. Place the client in the Trendelenburg position.

ANS: B An insertion-related complication of central venous catheters is a pneumothorax. Signs and symptoms of a pneumothorax include chest pain and dyspnea. Treatment includes removing the catheter, administering oxygen, and placing a chest tube. Pain is caused by the pneumothorax, which must be taken care of with a chest tube insertion. Use of a sterile dressing and placement of the client in a Trendelenburg position are not indicated for the primary problem of a pneumothorax. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Implementation)

4.A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next? a. Administer a sublingual nitroglycerin tablet. b. Prepare to assist with chest tube insertion. c. Place a sterile dressing over the IV site. d. Re-position the client into the Trendelenburg position.

ANS: B An insertion-related complication of central venous catheters is a pneumothorax. Signs and symptoms of a pneumothorax include chest pain and dyspnea. Treatment includes removing the catheter, administering oxygen, and placing a chest tube. Pain is caused by the pneumothorax, which must be taken care of with a chest tube insertion. Use of a sterile dressing and placement of the client in a Trendelenburg position are not indicated for the primary problem of a pneumothorax. DIF:Applying/ApplicationREF:194 KEY:Vascular access device| medical emergencies MSC:Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5.A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse? a. Redness at the catheter insertion site b. Report of headache and stiff neck c. Temperature of 100.1 F (37.8 C) d. Pain rating of 8 on a scale of 0 to 10

ANS: B Complications of epidural therapy include infection, bleeding, leakage of cerebrospinal fluid, occlusion of the catheter lumen, and catheter migration. Headache, neck stiffness, and a temperature higher than 101 F are signs of meningitis and should be reported to the provider immediately. The other findings are important but do not require immediate intervention. DIF:Applying/ApplicationREF:212 KEY:Vascular access device| medication safety| epidural MSC:Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

6. The RN assigned a new nurse to a client who was receiving chemotherapy through an intravenous extension set attached to a Huber needle. Which information about disconnecting the Huber needle is most important for the RN to provide to the new nurse? a. Apply topical anesthetic cream to the area after discontinuing the system. b. Be aware of a rebound effect when discontinuing the system. c. Be sure to flush the system with saline after removing the Huber needle. d. Place pressure over the site to prevent bleeding.

ANS: B Huber needles are used to access implanted ports placed under the skin. Because the dense septum holds tightly to the needle, a rebound can occur when it is pulled from the septum, often resulting in needle stick injury to the nurse. Topical anesthetic cream can be used when accessing the system. Flushing is carried out when the system is accessed and once monthly. Because the implanted port is not being removed, there is no need for a pressure dressing. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation)

41. The nurse is caring for a client admitted yesterday with an intraosseous (IO) infusion after a car crash. Which action by the nurse takes priority? a. Ensure that the IV flow rate has been recalculated for an IO infusion. b. Plan to insert another kind of IV line during the shift. c. Determine which IV medications can be given safely via the IO. d. Monitor the site and dressings routinely for hemorrhage.

ANS: B IO infusions, although valuable in an emergency, should be left in place for only 24 hours. The nurse should plan to insert a peripheral IV sometime during the shift. IV solutions, flow rates, and medications are given the same way that they are given IV. Hemorrhage is not a complication of IO infusion. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapyParenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation)

A nurse is caring for a client on an epidural patient-controlled analgesia (PCA) pump. What action by the nurse is most important to ensure client safety? a. Assess and record vital signs every 2 hours. b. Have another nurse double-check the pump settings. c. Instruct the client to report any unrelieved pain. d. Monitor for numbness and tingling in the legs.

ANS: B PCA-delivered analgesia creates a potential risk for the client. Pump settings should always be double-checked. Assessing vital signs should be done per agency policy and nurse discretion, and may or may not need to be this frequent. Unrelieved pain should be reported but is not vital to client safety. Monitoring for numbness and tingling in the legs is an important function but will manifest after something has occurred to the client; monitoring does not prevent the event from occurring.

37. A new nurse is securing the connections on a new IV administration set connected to a peripherally inserted central catheter (PICC) line with tape. Which action by the precepting nurse is most appropriate? a. Make sure the tape being used is from a sterile IV start kit. b. Stop the nurse and confirm that the Luer-Lok connections are tight. c. Help the new nurse document the set change appropriately. d. Show the new nurse how to turn back the corner of the tape for easy removal.

ANS: B PICC line administration sets must be secured using the Luer-Lok to help prevent air emboli. Using tape is not sufficient. When starting peripheral IVs, nurses must use the tape from the sterile IV start kit when possible, instead of using tape that might be dirty. Documentation is a critical function, but it does not take priority over doing a procedure correctly, nor does showing the new nurse time- and work-saving tips. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapyParenteral/Intravenous Therapies)

5. The nurse wants to find written standards for IV therapy. The nursing manager suggests that the nurse investigate publications from which resource? a. IV Therapy Nursing Society b. Infusion Nurses Society c. Nurses State Board of Nursing d. Hospitals IV solutions vendor

ANS: B The Infusion Nurses Society publishes guidelines and standards related to IV therapy and offers a national certification examination. The State Board of Nursing publishes legal information related to nursing practice, and the solutions vendor would have written information pertaining only to specific products. The IV Therapy Nursing Society does not exist, and the other organizations listed do not provide standards and guidelines related to IV therapy. DIF: Cognitive Level: Comprehension/Understanding REF: p. 211 TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlSafe Use of Equipment) MSC: Integrated Process: Nursing Process (Implementation)

38. The nurse is preparing to administer an infusion of dopamine (Intropin) using a smart pump. After programming the pump and attaching the IV to the client, what action by the nurse is most important? a. Start the infusion as ordered. b. Hand-calculate the infusion rate. c. Ensure that the pump is plugged in. d. Place a time tape on the IV bag.

ANS: B Using a smart pump does not relieve the nurse of the responsibility of ensuring that the rate is correct. Pumps can malfunction or can be programmed incorrectly, and concentrations of solution can change and differ from the pumps drug library. The nurse must hand-calculate the rate before starting the infusion, then must ensure that the pump is plugged into an electrical source. Time tapes on the sides of IV bags are no longer used to show approximate volume infused. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapyParenteral/Intravenous Therapies)

20. The home care nurse is about to administer intravenous medication to the client and reads in the chart that the peripherally inserted central catheter (PICC) line in the clients left arm has been in place for 4 weeks. The IV is patent, with a good blood return. The site is clean and free from manifestations of infiltration, irritation, and infection. Which action by the nurse is most appropriate? a. Notify the physician. b. Administer the prescribed medication. c. Discontinue the PICC line. d. Switch the medication to the oral route.

ANS: B A PICC line that is functioning well without inflammation or infection may remain in place for months or even years. Because the line shows no signs of complications, it is permissible to administer the IV antibiotic. The physician does not have to be called to have the IV route changed to an oral route. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation)

A patient with second-degree burns has been receiving hydromorphone through patient-controlled analgesia (PCA) for a week. The patient wakes up frequently during the night complaining of pain. What action by the nurse ismost appropriate? a. Administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping. b. Consult with the health care provider about using a different treatment protocol to control the patients pain. c. Request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain. d. Teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal.

ANS: B PCAs are best for controlling acute pain. This patients history indicates chronic pain and a need for a pain management plan that will provide adequate analgesia while the patient is sleeping. Administering a dose of morphine when the patient already has severe pain will not address the problem. Teaching the patient to administer unneeded medication before going to sleep can result in oversedation and respiratory depression. It is illegal for the nurse to administer the morphine for a patient through PCA.

The health care provider orders a patient-controlled analgesia (PCA) machine to provide pain relief for a patient with acute surgical pain who has never received opioids in the past. Which nursing actions regarding opioid administration are appropriate at this time (select all that apply)? a. Assess for signs that the patient is becoming addicted to the opioid. b. Monitor for therapeutic and adverse effects of opioid administration. c. Emphasize that the risk of some opioid side effects increases over time. d. Teach the patient about how analgesics improve postoperative activity levels. e. Provide instructions on decreasing opioid doses by the second postoperative day.

ANS: B, D Monitoring for pain relief and teaching the patient about how opioid use will improve postoperative outcomes are appropriate actions when administering opioids for acute pain. Although postoperative patients usually need a decreasing amount of opioids by the second postoperative day, each patients response is individual. Tolerance may occur, but addiction to opioids will not develop in the acute postoperative period. The patient should use the opioids to achieve adequate pain control, and so the nurse should not emphasize the adverse effects.

29. The nurse is caring for a client with an intraosseous catheter placed in the leg 20 hours ago. Which assessment is of greatest concern? a. Length of time catheter is in place b. Poor vascular access in upper extremities c. Affected leg cool to touch d. Site of intraosseous catheter placement

ANS: C Compartment syndrome is a condition in which increased tissue perfusion in a confined anatomic space causes decreased blood flow to the area. A cool extremity can signal the possibility of this syndrome. All other distractors are important. However, the possible development of a compartment syndrome requires immediate intervention because the client could require amputation of the limb if the nurse does not pick up this perfusion problem. DIF: Cognitive Level: Comprehension/Understanding REF: p. 235 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Assessment)

19. A client who has just had an IV started in the right cephalic vein tells the nurse that the wrist and the hand below the IV site feel like pins and needles. Which action by the nurse is best? a. Document the finding and continue to monitor the IV site. b. Check for the presence of a strong blood return. c. Discontinue the IV and restart it at another site. d. Elevate the extremity above the level of the heart.

ANS: C The sensation that the client has described is related to the IV needle touching the nerve or possibly transecting the nerve. This problem can lead to loss of function and the potential for permanent disability in the distal extremity. It is considered an emergency and the IV must be discontinued. Continuing just to monitor the IV site may lead to loss of function. The presence of blood return does not indicate absence of nerve damage. Elevation of the affected extremity does not ensure that the IV catheter has moved away from the nerve. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Implementation)

33. A new nurse is preparing to start an IV on a client who is dehydrated and needs significant fluid volume. The new nurse selects a butterfly needle for the infusion. What action by the supervising nurse is best? a. Help the new nurse with the procedure as needed. b. Make sure the new nurse has the correct dressing. c. Stop the new nurse and review the procedure in private. d. Get the ultrasonic vein finder to help illuminate veins.

ANS: C Winged (butterfly) needles generally are used for single doses of medications or for blood sampling. They would not be used for large volumes of fluid or kept in for any length of time. The other options do not acknowledge that the new nurses actions are incorrect and should be stopped. DIF: Cognitive Level: Application/Applying or higher TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapyParenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation)

A client is postoperative day one and has a patient-controlled analgesia (PCA) pump with a continuous basal dose for pain control. Currently, the client is stating that the operative pain is escalating. What is the first action of the nurse? a. Try diversion to take the clients mind off the pain. b. Ask the client to ambulate around the unit. c. Assess the clients pain according to PQRST. d. Call the physician to request an order to increase the basal dose.

ANS: C Assessment is the first step in the nursing process. The nurse will need the information gleaned from the assessment using PQRST (factors precipitating the pain, quality of the pain, region and radiation of the pain, severity of the pain, and timing of the pain) to request a change in medication order. Diversion and ambulation can be used in client care but will not control escalating pain in the postoperative client. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration) MSC: Integrated Process: Nursing Process (Assessment)

26. The nurse is caring for a client with a radial arterial catheter. Which assessment takes priority? a. Amount of pressure in fluid container b. Date of catheter tubing change c. Checking for heparin in infusion container d. Presence of an ulnar pulse

ANS: D An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased perfusion to the extremity. Assessment of ulnar pulse is one way to assess circulation to the arm in which the catheter is located. 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. Because of heparin-induced thrombocytopenia, heparin is not used in most institutions for an arterial catheter. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation)

27. Five days after the start of intraperitoneal therapy, the client reports abdominal pain and feeling warm. The nurse prepares to assess the client further for evidence of which condition? a. Allergic reaction b. Bowel obstruction c. Catheter lumen occlusion d. Infection

ANS: D Fever, abdominal pain, abdominal rigidity, and rebound tenderness may be present in the client who has peritonitis related to intraperitoneal therapy. Peritonitis is preventable by using strict aseptic technique in handling all equipment and infusion supplies. An allergic reaction would occur earlier in the course of treatment. Bowel obstruction and catheter lumen occlusion can occur but would present clinically in different ways. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationUnexpected Response to Therapies) MSC: Integrated Process: Nursing Process (Analysis)

23. When assessing a clients peripheral IV site, the nurse notices edema and tenderness above the site. What action does the nurse take first? a. Apply cold compresses to the IV site. b. Elevate the extremity on a pillow. c. Flush the catheter. d. Stop the infusion of IV 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 should 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 by institutional policy and may help speed circulation to the area. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationUnexpected Response to Therapies) MSC: Integrated Process: Nursing Process (Implementation)

15. In examining a peripheral IV site, the nurse observes a red streak along the length of the vein, and the vein feels hard and cordlike. What action by the nurse takes priority? a. Applying continuous heat b. Continuing to monitor site c. Elevating the extremity d. Removing the catheter

ANS: D The clinical manifestations described are those associated with phlebitis. Phlebitis is an inflammation of the vein. Its presence in a vein being used for IV therapy may be caused by mechanical forces associated with the IV device, or by chemical factors related to the composition and osmolarity of the drug solution. The key manifestation is that symptoms are directly associated with the vein, and the catheter must be removed. Warm compresses can be applied for 20 minutes four times daily after the catheter is removed. The site needs to be monitored after the catheter is removed. The arm is not swollen. Therefore, elevation of the extremity is not a correct option. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation)

6.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 clients left lower extremity is cool to the touch.

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 clients left lower extremity is cool to the touch. ANS: D Compartment syndrome is a condition in which increased tissue perfusion 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 this perfusion problem. DIF:Applying/ApplicationREF:211 KEY:Vascular access device MSC:Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

39. A student nurse is preparing to take a blood pressure (BP) on a client who has a peripheral IV line in the left arm. What instruction by the faculty member is most important? a. Use the arm that doesnt have the IV site in it. b. Dont inflate the cuff too high if you use the left arm. c. Make sure the IV line is secure before taking the BP. d. While the BP is taken, a little backflow of the IV is okay.

ANS: A Nurses should not take blood pressure on arms that have IVs because increased pressure can cause infiltration and can cause fluid to leak from the insertion site. Because the affected arm should not be used for BP, none of the other options can be correct. DIF: Cognitive Level: Comprehension/Understanding REF: p. 224 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapyParenteral/Intravenous Therapies)

8. When assessing the clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. What is the most accurate documentation of 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, infiltration, or thrombosis is present. DIF: Cognitive Level: Comprehension/Understanding REF: Table 15-6, p. 233 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Assessment)

10. A client is to receive 10 days of antibiotic therapy for urosepsis. The nurse plans to insert which type of intravenous catheter? a. Hickman b. Midline c. Nontunneled central d. Short peripheral

ANS: B Midline catheters are used for therapies lasting from 1 to 4 weeks. Short peripheral catheters can be inserted by the nurse for use with antibiotic therapy, but they can stay in only for up to 96 hours. If the length of IV therapy is longer than 6 days, a midline catheter should be chosen. Nontunneled central catheters and Hickman catheters are inserted by a physician. DIF: Cognitive Level: Comprehension/Understanding REF: p. 215 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation)

7. A client with chronic anemia has had many blood transfusions. What medications does the nurse anticipate teaching the client about adding to the regimen? (Select all that apply.) a. Azacitidine (Vidaza) b. Darbepoetin alfa (Aranesp) c. Decitabine (Dacogen) d. Epoetin alfa (Epogen) e. Methylprednisolone (Solu-Medro

ANS: B, D Darbepoetin alfa and epoetin alfa are both red blood cell colony-stimulating factors that will help increase the production of red blood cells. Azacitidine and decitabine are used for myelodysplastic syndromes. Methylprednisolone is a steroid and would not be used for this problem.

14.A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain? a. Administer topical lidocaine to the site. b. Place warm compresses on the site. c. Administer prescribed oral pain medication. d. Massage the site with scented oils.

ANS: B At the first sign of phlebitis, the catheter should be removed and warm compresses used to relieve pain. The other options are not appropriate for this type of pain. DIF:Applying/ApplicationREF:205 KEY:Vascular access device| nonpharmacologic pain management MSC:Integrated Process: Caring NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

SHORT ANSWER 1. A client is scheduled to receive 1000 mL of normal saline in 24 hours. The nurse should set the infusion pump to deliver how many milliliters per hour? _____________ mL/hr

ANS:42 1000 mL divided by 24 hours = 41.6 mL/hr DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation)

9.While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should 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. DIF:Understanding/ComprehensionREF:209 KEY:Vascular access device MSC:Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

4.A nurse assists with the insertion of a central vascular access device. Which actions should 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 clients plan of care. b. Remind the provider to perform hand hygiene prior to starting the procedure. 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.

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 should wear sterile gloves, gown and mask, and anyone in the room should wear a mask. A sterile dressing change should be completed per organizational policy, usually every 7 days and as needed. DIF:Remembering/KnowledgeREF:204 KEY:Vascular access device| infection control| infection MSC:Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

3. A client has a peripherally inserted central catheter (PICC) line and the primary nurse is updating the care plan. For which common complications does the nurse assess? (Select all that apply.) a. Phlebitis b. Pneumothorax c. Thrombophlebitis d. Excessive bleeding e. Extravasation

ANS: A, C Although the complication rate with PICC lines is fairly low, the most common complications are phlebitis, thrombophlebitis, and catheter-related bloodstream infection. Pneumothorax, excessive bleeding, and extravasation are not common complications. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Diagnostic Tests/Treatments/Procedures)

7. After discontinuing a nontunneled, percutaneous central catheter, it is most important for the nurse to record which information? a. Application of a sterile dressing b. Length of the catheter c. Occurrence of venospasms d. Type of ointment used to seal the tract

ANS: B After removal of a catheter, measure the catheter length and compare it with the length documented on insertion. If the entire length has not been removed, the nurse should contact the physician immediately because some of the catheter may still be in the clients vein. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation)

20. 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. Documenting the events in the clients medical record b. Double-checking the client and blood product identification c. Placing the client on strict bedrest until the pain subsides d. Reviewing the clients medical record for known allergies

ANS: B This client 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 is not related

32. The nurse has just performed an IV start on a client. After the catheter has been threaded its full length in the clients vein, which action does the nurse perform next? a. Secure the IV with a securement device or tape. b. Dispose of the IV needle in the sharps container. c. Engage the safety mechanism of the IV catheter d. Note the date and time of the dressing application over the insertion site.

ANS: C A federal law enacted in 2000 requires health care facilities to use IV catheters with an engineered safety mechanism to prevent needle sticks, which can be a source of contamination by bloodborne pathogens. This priority action would help keep the nurse safe. Securing the IV and dating/timing the dressing are also important actions, but engaging the safety mechanism comes first. After engaging the safety mechanism, safely dispose of the needle in the sharps container. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlSafe Use of Equipment)

A registered nurse (RN) and nursing student are caring for a client who is receiving pain medication via patient-controlled analgesia (PCA). What action by the student requires the RN to intervene? a. Assesses the clients pain level per agency policy b. Monitors the clients respiratory rate and sedation c. Presses the button when the client cannot reach it d. Reinforces client teaching about using the PCA pump

ANS: C The client is the only person who should press the PCA button. If the client cannot reach it, the student should either reposition the client or the button, and should not press the button for the client. The RN should intervene at this point. The other actions are appropriate.

1. Before the administration of intravenous fluid, it is most important for the nurse to obtain which information from the health care providers orders? a. Intravenous catheter size b. Osmolarity of the solution c. Vein to be used for therapy d. Specific type of IV fluid

ANS: D An order for infusion therapy must contain the following to be complete: specific type of fluid, rate of administration, and drugs added to the solution. Osmolarity of the solution is not necessary because it is incorporated into the specific type of fluid. It is the nurses independent decision about the most appropriate vein to cannulate and the catheter size to use. DIF: Cognitive Level: Comprehension/Understanding REF: p. 212 TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlError Prevention) MSC: Integrated Process: Nursing Process (Assessment)

8. A nurse is preparing to administer a blood transfusion to an older adult. Understanding age-related changes, what alterations in the usual protocol are necessary for the nurse to implement? (Select all that apply.) a. Assess vital signs more often. b. Hold other IV fluids running. c. Premedicate to prevent reactions. d. Transfuse smaller bags of blood. e. Transfuse each unit over 8 hours.

ANS: A, B The older adult needs vital signs monitored as often as every 15 minutes for the duration of the transfusion because 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. The other options are not warranted

2. Which IV order does the nurse question? a. Flush Groshong catheter with 10 mL normal saline every 8 hours. b. Infuse 20 mEq potassium chloride in 1000 mL D5W at 50 mL/hr. c. Infuse 500 mL normal saline over 1 hour. d. Infuse 0.9% normal saline at keep vein open (KVO) rate.

ANS: D To be complete, IV orders for infusion fluids should specify the rate of infusion. This order does not specify the rate of infusion and is not considered complete. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlError Prevention) MSC: Integrated Process: Nursing Process (Analysis)

19. A nurse is preparing to hang a blood transfusion. Which action is most important? a. Documenting the transfusion b. Placing the client on NPO status c. Placing the client in isolation d. Putting on a pair of gloves

ANS: D To prevent bloodborne illness, the nurse should don a pair of gloves prior to hanging the blood. Documentation is important but not the priority at this point. NPO status and isolation are not needed.

2. If a client is to receive an entire 250-mL bag of saline over the next 4 hours and the drop rate of the IV tubing chamber is 15 drops/mL, at what drop rate per minute will the nurse set this IV? ____________ drops/min

ANS: 16 Drops per minute = volume drop factor total minutes 250 15 = 15.625 4 (hours) 60 (minutes/hour) DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation)

30. A client is receiving an infusion of amiodarone (Cordarone), and the nurse notes that the clients arm has begun to blister around the IV site. This manifestation is consistent with which condition? a. Extravasation b. Infiltration c. Infection d. Phlebitis

ANS: A Certain medications, including amiodarone, vancomycin, and ciprofloxacin, are venous irritants that can cause tissue sloughing and necrosis if the IV infiltrates. The other three complications are possible with any infusion and are not specific to amiodarone. DIF: Cognitive Level: Knowledge/Remembering REF: p. 211 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MULTIPLE RESPONSE 1.A registered nurse (RN) delegates client care to an experienced licensed practical nurse (LPN). Which standards should guide the RN when delegating aspects of IV therapy to the LPN? (Select all that apply.) a. State Nurse Practice Act b. The facilitys Policies and Procedures manual c. The LPNs level of education and experience d. The Joint Commissions goals and criterion e. Client needs and prescribed order

s ANS: A, B The state Nurse Practice Act will have the information the RN needs, and in some states, LPNs are able to perform specific aspects of IV therapy. However, in a client care situation, it may be difficult and time-consuming to find it and read what LPNs are permitted to do, so another good solution would be for the nurse to check facility policy and follow it. DIF:Applying/ApplicationREF:188 KEYelegation| competencies MSC:Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

3.A nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) universal bar-coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply.) a. Unique facility identifier b. Lot number related to the donor c. Name of the client receiving blood d. ABO group and Rh type of the donor e. Blood type of the client receiving blo

od ANS: A, B, D The ISBT universal bar-coding system includes four components: (1) the unique facility identifier, (2) the lot number relating to the donor, (3) the product code, and (4) the ABO group and Rh type of the donor. DIF:Remembering/KnowledgeREF:188 KEY:Blood transfusion| safety MSC:Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

14. The nurse is assessing several clients receiving intravenous therapy. Which client situation requires immediate intervention? a. Completion of an intermittent medication into a Groshong catheter b. Physicians order to discontinue a peripheral intravenous catheter c. Nonaccessed implanted port placed 1 month ago without problem d. Peripheral IV catheter dated 5 days ago used for once-daily antibiotics

ANS: A A Groshong catheter is a peripherally inserted catheter that needs to be flushed with saline after intermittent use. Peripheral IV catheters should be discontinued after 4 days, so this one should be changed however, this is not the priority. An order to discontinue the peripheral catheter requires intervention, but flushing of the Groshong catheter is more of an immediate intervention to prevent clotting of the catheter. A nonaccessed implanted port site needs to be assessed, but this is not an immediate intervention. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Implementation)

5. A student nurse is helping a registered nurse with a blood transfusion. Which actions by the student are most appropriate? (Select all that apply.) a. Hanging the blood product using normal saline and a filtered tubing set b. Taking a full set of vital signs prior to starting the blood transfusion c. Telling the client someone will remain at the bedside for the first 5 minutes d. Using gloves to start the clients IV if needed and to handle the blood product e. Verifying the clients 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 30 minutes of the transfusion. Two registered nurses must verify the clients identity and blood compatibility.

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

ANS: A, C Although the complication rate with PICCs is fairly low, the most common complications are phlebitis, thrombophlebitis, and catheter-related bloodstream infection. Pneumothorax, excessive bleeding, and extravasation are not common complications. DIF:Applying/ApplicationREF:194 KEY:Vascular access device MSC:Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A student nurse is learning about blood transfusion compatibilities. What information does this include? (Select all that apply.) a. Donor blood type A can donate to recipient blood type AB. b. Donor blood type B can donate to recipient blood type O. c. Donor blood type AB can donate to anyone. d. Donor blood type O can donate to anyone. e. Donor blood type A can donate to recipient blood type B.

ANS: A, D Blood type A can be donated to people who have blood types A or AB. Blood type O can be given to anyone. Blood type B can be donated to people who have blood types B or AB. Blood type AB can only go to recipients with blood type AB.

13.A nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this clients teaching? a. You will need to wear a sling on your arm while the device is in place. b. There is no risk of infection because sterile technique will be used during insertion. c. Ask all providers to vigorously clean the connections prior to accessing the device. d. You will not be able to take a bath with this vascular access device.

ANS: C Clients should be actively engaged in the prevention of catheter-related bloodstream infections and taught to remind all providers to perform hand hygiene and vigorously clean connections prior to accessing the device. The other statements are incorrect. DIF:Applying/ApplicationREF:204 KEY: Vascular access device| Speak Up campaign| patient safety| infection control MSC:Integrated Process: Teaching/Learning NOT:Client Needs Category: Health Promotion and Maintenance

11. A client is admitted to the hospital for excessive nausea and vomiting, and a blood pressure of 90/50 mm Hg. A catheter of which gauge is most appropriate for the nurse to choose for this clients peripheral IV? a. 24 b. 22 c. 20 d. 18

ANS: C The nurse selects the access device most appropriate for the designated purpose. In this case, because a large amount of fluid will be needed as a result of excessive fluid loss, the appropriate needle is the 20-gauge catheter IV, because this is the most commonly used size in adults and it can be used for all fluids. The 22- and 24-gauge catheters will have a slower rate of flow, which may not be desirable with excessive fluid losses and low blood pressure. The 18-gauge catheter allows rapid flow of IV fluids. However, it requires a large vein and is more prone to irritation to the vein wall. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation)

12.A nurse delegates care to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene for a client who has a vascular access device? a. Provide a bed bath instead of letting the client take a shower. b. Use sterile technique when changing the dressing. c. Disconnect the intravenous fluid tubing prior to the clients bath. d. Use a plastic bag to cover the extremity with the device.

ANS: D The nurse should ask the UAP to cover the extremity with the vascular access device with a plastic bag or wrap to keep the dressing and site dry. The client may take a shower with a vascular device. The nurse should disconnect IV fluid tubing prior to the bath and change the dressing using sterile technique if necessary. These options are not appropriate to delegate to the UAP. DIF:Applying/ApplicationREF:201 KEY:Vascular access device| delegation| unlicensed assistive personnel MSC:Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

9. What information is most important to teach the client going home with a peripherally inserted central catheter (PICC) line? a. Avoid carrying your grandchild with the arm that has the IV. b. Be sure to place the arm with the IV in a sling during the day. c. Flush the IV line with normal saline daily. d. You can use the arm with the IV for most of the 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning

8.A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should 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 should 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. DIF:Applying/ApplicationREF:206 KEY:Vascular access device| medication safety MSC:Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

17. The nurse is caring for four clients receiving IV therapy. Which client does the nurse assess first? a. Client with a newly inserted peripherally inserted central catheter (PICC) line waiting for x-ray b. Client with a peripheral catheter for intermittent infusions c. Older adult client with a nonaccessed implanted port d. Older adult client with normal saline infusion

ANS: D Older adults are more prone to fluid overload and resulting congestive heart failure. Because this client is receiving continuous IV fluid, he or she is at risk for fluid overload and needs to be assessed. All other clients would need to be assessed for complications of IV catheters. However, they do not need immediate assessment. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Analysis)

7.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 should 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 should have one, but this does not take priority over the client whose arm is swollen. DIF:Applying/ApplicationREF:193 KEY:Vascular access device| medication safety MSC:Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

31. A client is to receive a blood transfusion. Before the transfusion, what action by the nurse takes priority? a. Verifying the clients identity b. Ensuring that the blood bank has enough blood c. Establishing a peripheral IV site d. Feeding the client before starting the blood

ANS: A Blood transfusion reactions can be devastating and can be prevented in large measure by positive client identification. This is accomplished by two professionals using two different client identifiers. Ensuring that the blood bank has enough blood would not be a normal nursing action, and transfusions can be given without regard to food and drink. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlError Prevention)

21. Which assessment finding for a client with a peripherally inserted central catheter (PICC) line requires immediate attention? a. Initial dressing over site is 3 days old. b. Line has been in for 4 weeks. c. A securement device is absent. d. Upper extremity swelling is noted.

ANS: D Upper extremity swelling could indicate infiltration, and the PICC line will need to be removed. The initial dressing over the PICC site should be changed within 24 hours. This does not require immediate attention, but the swelling does. The dwell time for PICC lines 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 should have one, but this does not take priority over the client whose arm is swollen. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationUnexpected Response to Therapies) MSC: Integrated Process: Nursing Process (Implementation)

3.A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this clients 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. DIF:Applying/ApplicationREF:194 KEY: Vascular access device MSC: Integrated Process: Teaching/Learning NOT:Client Needs Category: Health Promotion and Maintenance

The nurse is caring for a 1-day postoperative patient who is receiving morphine through patient-controlled analgesia (PCA). What action by the nurse is a priority? a. Check the respiratory rate. b. Assess for nausea after eating. c. Inspect the abdomen and auscultate bowel sounds. d. Evaluate the sacral and heel areas for signs of redness.

ANS: A The patients respiratory rate is the highest priority of care while using PCA medication because of the possible respiratory depression. The other information may also require intervention but is not as urgent to report as the respiratory rate.

Chapter 13

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