CHAPTER 13: AQ (

The nurse is teaching a hospitalized patient who is being discharged about how to care for a peripherally inserted central catheter (PICC) line. Which patient statement indicates a need for further education?

-"I can continue my 20-mile running schedule as I have for the past 10 years." Rationale: Excessive physical activity can dislodge the PICC and should be avoided. Patients with PICCs should be able to perform normal activities of daily living. PICCs have low 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 patient statement is of greatest concern during this procedure?

-"My hand tingles when you poke me." Rationale: The patient's statement about a tingling feeling indicates possible nerve puncture. To avoid further nerve damage, the nurse should stop immediately, remove the IV catheter, and choose a new site. The other statements indicate a need for patient teaching, but are not indicators of immediate complications of catheter insertion—pain at the insertion site is common, and IV sites that "never last very long" should be addressed with teaching about the importance of proper protection of the site.

Which statement made by a student nurse regarding the guidelines published by the Occupational Safety and Health Administration (OSHA) on needleless connection devices indicates a need for further education?

-"The goal of the guidelines is to limit the transmission and spread of airborne pathogens." Rationale: The OSHA guidelines have the goal of limiting the spread of bloodborne, not airborne, pathogens. The Occupational Exposure to Bloodborne Pathogens, Final Rule necessitates the use of devices developed with safety mechanisms. It also requires each employer to maintain a log regarding sharps injury along with the incident details. The Occupational Exposure to Bloodborne Pathogens, Final Rule was revised in 2001 as per the Needlestick Safety and Prevention Act.

What is the pore size (in microns) of a filter for removing all particles and bacteria in infusion systems?

-0.2 Rationale: Filters are a part of an administration set used to remove particulate matter, microorganisms, and other contaminants from the infusion system. Filter sizes depend on the pore size, with common sizes being 0.2 microns intended to remove all particles and bacteria and 1.2 microns used to filter lipid-containing parenteral nutrition. Microaggregate filters used on blood administration sets have a pore size of 20, 40, or 80 microns and are used to remove degenerating platelets, white blood cells, and fibrin strands.

What is the osmolarity of a hypotonic infusate?

-250 mOsm/L Rationale: If the osmolarity of IV infusate is less than the serum osmolarity, the infusate is called hypotonic. Normal serum osmolarity is 270 mOsm/L-300 mOsm/L. Therefore, 250 mOsm/L is a hypotonic solution. The osmolarity of 300 mOsm/L is related to isotonic infusate; whereas 350 mOsm/L and 400 mOsm/L are the osmolarities of hypertonic IV solutions.

A patient is prescribed intravenous antibiotics for 4 weeks. How often should the nurse change the gauze dressing?

-48 hours Rationale: The gauze dressing of a midline catheter should be changed every 48 hours. The dressing is changed within 24 hours after a catheter insertion. Changing the dressing every 36 hours may not be necessary unless it is either saturated or soiled. Changing the gauze dressing every 72 hours can lead to an infection.

What would be the osmolarity of fluids and medications that are infused through a midline catheter?

-575 mOsm/L Rationale: The osmolarity of fluids and medications that are infused through a midline catheter should be less than 600 mOsm/L. Therefore, 575 mOsm/L is appropriate. If the osmolarity is greater than 600 mOsm/L, phlebitis and thrombosis may occur.

A patient is being admitted to the burn unit from another hospital. The patient has an intraosseous IV that was started 2 days ago, according to the patient's medical record. What does the admitting nurse do first?

-Anticipate an order to discontinue the intraosseous IV and start an epidural IV. Rationale: 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 patient's situation without contacting the previous hospital. Other patient 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 patient 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 who is starting the shift finds a patient with an IV that is leaking all over the bed linens. What does the nurse do initially?

-Assess the insertion site. Rationale: Assessing the insertion site to check for patency is the priority. IV assessments typically begin at the insertion site and move "up" the line; that is, 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.

The nurse is preparing to administer an IV solution to a patient who underwent a recent mastectomy. What must the nurse remember when choosing a site for placement of a short peripheral venous catheter?

-Avoid the arm on the side of the mastectomy. Rationale: The nurse should avoid the arm on the side of the mastectomy when choosing a site for placement of a short peripheral venous catheter. Similarly, the arm on the side of a lymph node dissection, arteriovenous shunt or fistula, or paralysis is not considered for placement of a short peripheral venous catheter, because they alter the normal pattern of blood flow through the arm. Generally, a site should be chosen in the upper extremity for adults, but not the wrist because of the possibility of puncturing the median nerve. A vein that is hard or cordlike is not suitable for placement of the catheter. The site on the inner side of the elbow or in the area of a joint flexion is generally avoided because it causes immobilization of the arm.

Which type of intravenous therapy-acquired infection is most responsible for increased death rates?

-Catheter-related bloodstream Rationale: The Institute for Health Care Development identified catheter-related bloodstream infections (CR-BSI) as a severe hospital-acquired infection responsible for about 28,000 deaths per year. Hand hygiene of hospital staff and selection of the appropriate infusion site can reduce the risk of CR-BSI to a greater extent. Peritonitis is the inflammation and infection of the peritoneum, usually acquired in the hospital by peritoneal administration of medications. Meningitis is the inflammation of the meninges and can be caused in the hospital by the intraspinal administration of medications. Joint infection can be caused when medications are administered into a joint cavity.

Which veins may lead to nerve damage if used for intravenous therapy? Select all that apply.

-Cephalic vein near the wrist -Veins on the palmar side of the wrist Rationale: The cephalic vein near the wrist and veins near the palmar side of the wrist should not be used for infusion therapy to prevent nerve damage. Radial veins in the forearms, basilic veins in the upper arms, and cephalic veins in the upper arms can be used for infusion therapy. These veins are not associated with nerve damage.

The nurse is administering a drug to a patient through an implanted port. Before giving the medication, what does the nurse do to ensure safety?

-Check for blood return Rationale: Before a drug is given through an implanted port, it is critical that the nurse check for blood return. If no blood return is observed, the drug should be held until patency is reestablished. 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 patient's safety.

A patient is prescribed intravenous antibiotics for four weeks. What is the most important assessment the nurse should perform after the peripherally inserted central catheter (PICC) is inserted in the brachial vein to prevent complications?

-Check for signs of phlebitis in the patient's upper chest Rationale: Midline and peripherally inserted central catheter (PICC) venous access devices are the most appropriate catheters to infuse antibiotics for four weeks. Because the line runs through the vasculature of the entire extremity with the tip resting in the superior vena cava, the nurse should check for signs of phlebitis. The length of the catheter and location of the catheter tip should be assessed for all infusion systems. Signs of thrombosis in the lower extremities will be associated with PICC lines that are placed in the femoral vein.

The nurse checking an IV fluid order questions its accuracy. What does the nurse do first?

-Contacts the health care provider who ordered it Rationale: The nurse is responsible for accuracy and has the duty to verify the order with the health care provider who ordered it. Although the nurse can consult the charge nurse, this is not the definitive action that the nurse should take. Contacting the pharmacy is not the definitive action that the nurse should take. Giving (or starting) the fluid when the order is questionable is not appropriate.

What should the nurse document after inserting a venous catheter?

-Date and time of the insertion

What is the expected risk for a patient who had a total parenteral nutrition (TPN) solution with an osmolarity of 1500 mOsm/L infused peripherally?

-Decreased perfusion Rationale: Fluids and medications with an osmolarity more than 600 mOsm/L are best infused in the central circulation where greater blood flow provides adequate hemodilution. If TPN is infused peripherally, it damages blood cells and the endothelial lining of the veins, decreasing perfusion. Thrombi can form as a result of vessel irritation. An infiltration happens when an infusion of a nonvesicant solution leaks into surrounding tissues from the veins. Extravasation results from an infusion of a vesicant solution that leaks into surrounding tissues from the veins.

A patient with a central venous catheter reports back pain between the shoulder blades. What should be the immediate nursing intervention in this situation?

-Discontinuing all infusions and flushing the central venous line Rationale: Back pain between the shoulder blades is a sign of catheter migration [1] [2]. The nurse should immediately stop the infusion and flush the catheter. Repositioning the catheter tip is a better intervention than changing the entire infusion system in this situation. A chest X-ray is always needed to assess the catheter tip; this action can be performed when the symptoms have subsided. The nurse should inform the primary health care provider after discontinuing the infusion.

An older adult patient receiving intravenous steroid therapy reports swelling, pain, and tenderness at the insertion site. Which immediate complication may the patient develop?

-Ecchymosis Rationale: Swelling, pain, and tenderness at the intravenous insertion site are common signs of phlebitis [1] [2], infiltration, ecchymosis, and thrombosis. However, the most common complication seen in older adults with steroid therapy is ecchymosis. In older patients, the nurse should refrain from using hard veins to prevent phlebitis. An infiltration is not an immediate possible complication. Thrombosis is seen due to damage of a vein after catheter insertion; however, it may not be an immediate complication.

The nurse is to administer a unit of whole blood to a postoperative patient. What does the nurse do to ensure the safety of the blood transfusion?

-Ensures that another qualified health care professional checks the unit before administering Rationale: 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 patient 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 patient 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 patient. Patients 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.

The nurse is caring for a patient with a peripherally inserted central catheter (PICC). What could cause this catheter to become dislodged?

-Excessive physical activity Rationale: Patients with PICCs should be instructed to avoid excessive physical activity because it may result in the dislodgement of the catheter and the development of lumen occlusion. Phlebitis, thrombophlebitis, and catheter-related bloodstream infections do not cause dislodgement of the catheter, but they are possible complications during infusion therapy.

Which is the least preferred site for peripherally inserted central catheters (PICC)?

-Femoral vein Rationale: Because there is a higher risk for infection, the femoral vein is the least preferred site for a PICC line insertion. The basilic vein is preferred because it offers the largest diameter of the blood vessels. The subclavian vein is also preferred because it is easy to access using bony landmarks, followed by an internal jugular vein. The basilic, subclavian, and internal jugular veins have a lower risk for infection than the femoral vein.

When is intraosseous (IO) infusion therapy contraindicated? Select all that apply.

-Fracture -Osteoporosis -Osteogenesis imperfecta Rationale: Fracture, osteoporosis, and osteogenesis imperfecta are contraindications to use of the IO route. Osteomyelitis and compartment syndrome are complications of the IO route.

A patient is seen in the emergency department (ED) with pain, redness, and warmth of the right lower arm. The patient was in the ED last week after an accident at work. On the day of the injury, the patient was in the ED for 12 hours receiving IV fluids. On close examination, the nurse notes the presence of a palpable cord 1 inch in length and streak formation. How does the nurse classify this patient's phlebitis?

-Grade 3 Rationale: Grade 3 indicates pain at the access site with erythema and/or edema and streak formation with a palpable cord. Grade 1 indicates only erythema with or without pain; the patient has additional symptoms. Grade 2 indicates only pain at the access site with erythema and/or edema; the patient 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, and purulent drainage. No purulent drainage is present in this patient, and the palpable cord is 1 inch in length.

What manifestations of catheter-related complications does the nurse observe in a patient undergoing intraspinal infusion therapy? Select all that apply.

-Infection -Bleeding Rationale: Infection at the site of intraspinal infusion is commonly observed with this type of infusion therapy and indicates complications. Bleeding may also be observed as a result of forceful or sudden withdrawal of the catheter from the site of insertion. Peritonitis is a common complication of intraperitoneal infusion. Osteomyelitis is a common complication of intraosseous infusion. Arterial occlusion is a common complication of intra-arterial infusion.

The nurse observes that a patient with intravenous (IV) fluids infusing via a peripheral catheter has developed skin tightening, tenderness, coolness of the skin, and fluid leaking from the insertion site. Which complication does the nurse suspect in this patient?

-Infiltration Rationale: Skin tightening, tenderness, coolness of the skin, and fluid leaking from the insertion site indicate that the patient has developed an infiltration [1] [2]. Phlebitis is characterized by redness and inflammation of the vein. Ecchymosis is characterized by swelling, bruising, pain, or tenderness. Thrombosis is characterized by a swollen extremity and engorged peripheral veins of the ipsilateral chest and extremities.

Which complication is common in both thrombophlebitis and phlebitis?

-Inflammation Rationale: Inflammation is a common complication seen in both thrombophlebitis and phlebitis. Infiltration, contraction (venous spasm), and extravasation are complications of infusion therapy.

Which infusion therapy route is often used in the administration of chemotherapeutic agents into arterial blood flow?

-Intra-arterial Rationale: Intra-arterial therapy is used for infusing chemotherapeutic agents into the arterial blood flow. The radial, brachial, and femoral arteries are the sites of choice for this therapy. Intraspinal therapy is used for infusions in the epidural space of the spinal cord. Infusions to the bone marrow are facilitated by intraosseous therapy. Intraperitoneal therapy involves infusions to the peritoneal cavity.

A tunneled central venous catheter (CVC) is used for lifetime parenteral nutrition. Which are commercial trade names of the catheters that are available? Select all that apply.

-Leonard -Hickman Rationale: CVCs were originally named for the physicians who designed them, including Leonard, Hickman, and Broviac catheters. The PreSep CVC is a non-tunneled CVC. Insyte BD and angiocath BD catheters are short peripheral catheters.

What type of anesthetic is typically used for inserting a catheter for intraosseous (IO) therapy?

-Local Rationale: Before intraosseous insertion, a lidocaine concentration of 1% is commonly used to anesthetize the skin, subcutaneous tissue, and periosteum to promote comfort. Local anesthetics are also administered epidurally for intraspinal infusion insertion. Topical anesthetic creams are sometimes used for other forms of venous access, such as implanted ports. General anesthesia is not typically used for infusion therapy insertions. Sometimes anesthetic is not needed to establish certain forms of venous access, depending on the type, but anesthetic is typically used to establish IO therapy access.

The nurse is transfusing blood to a patient. Which components should the nurse be sure to check on the blood label? Select all that apply.

-Lot number -Product code -ABO group and Rh factor Rationale: The International Society of Blood Transfusion (ISBT) designed a universal bar-code system that ensures the transfusion of the right blood to the right person. The bar code consists of the lot number of the donor, the product code, and the ABO group and Rh factor of the blood. Dosage is important during administration of drugs. Tonicity refers to the nature of IV fluids to be isotonic, hypertonic, or hypotonic.

Which veins are most appropriate for common peripheral catheter placement? Select all that apply.

-Median -Cephalic -Basilic Rationale: The veins that are most appropriate for common peripheral catheter placement include the median, cephalic, and basilic vein. The jugular vein and vena cava are not typically used for peripheral catheter placement.

The nurse is preparing to administer a blood transfusion to a patient. Which vein is selected for a midline catheter?

-Median antecubital Rationale: The median antecubital vein is the preferred site for the administration of a midline catheter because it does not require vein transillumination for visualization. The basilic vein, which is the second choice for midline catheter administration, requires ultrasound visualization. The cephalic, subclavian, and internal jugular veins are not used for midline catheter placement. The cephalic vein is the site of placement for short peripheral catheters. The subclavian and internal jugular veins are used for placement of nontunneled percutaneous central venous catheters.

While the nurse is attempting to remove a midline catheter from a patient, the patient develops venospasms. Which technique does the nurse use to facilitate the removal of the catheter in this patient?

-Medication administration Rationale: Veins can develop venospasms when rapid or forceful catheter removal techniques are used. Use of medications to relax the vein wall may be required if the catheter cannot be removed. Imaging studies can confirm whether the cause of removal failure is a thrombosis instead of venospasm. Extreme traction or forceful removal of a catheter could cause the catheter to break and embolize to the heart or pulmonary circulation. Clipping of sutures is used for the removal of non-tunneled percutaneous central catheters. Breaking the catheter is never an option.

Which regulation or act requires every health care facility to maintain a sharps injury log with details of each incident?

-Needlestick Safety and Prevention Act

A patient receiving intravenous therapy reports tingling and numbness at the insertion site. What could be the possible complication?

-Nerve damage Rationale: Tingling and numbness at the insertion site are the signs of nerve damage. Nerve damage is due to vein puncture at or near the nerve location. Ecchymosis is the infiltration of blood into the surrounding tissues. It may cause swelling, bruising, pain, or tenderness. Thrombosis is characterized by swollen extremities and engorged veins of the ipsilateral chest. Venous spasms are sudden vein contractions caused by vein irritation or injury. This condition causes cramping or pain at the insertion site.

Which catheter is preferred in emergency or trauma situations?

-Nontunneled percutaneous central venous catheters Rationale: Nontunneled percutaneous central venous catheters are preferred in emergency or trauma situations. An implanted port is used for patients who would require intravenous (IV) therapy for more than a year. Midline catheters are used for therapies lasting from 1 to 4 weeks. Tunneled central venous catheters are used primarily when the need for infusion therapy is frequent and long term.

Which patient does the charge nurse on a medical-surgical unit assign to the LPN/LVN?

-Older patient admitted for confusion who has a heparin lock that needs to be flushed every 8 hours Rationale: The older patient 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 cardiac patient with a diltiazem IV infusion, the diabetic patient on an IV insulin drip, and the postoperative patient receiving blood products all are not stable and will require ongoing assessments and adjustments in IV therapy that should be performed by an RN.

Which is a complication of intraosseous (IO) infusion therapy?

-Osteomyelitis Rationale: Osteomyelitis is the serious complication of IO therapy. Osteoporosis and osteogenesis are contraindications to IO therapy. Osteoarthritis is not associated with IO therapy.

Which principles from the catheter-related bloodstream infection prevention bundle (CRBSI) are important to remember when assisting with the placement of a central line? Select all that apply.

-Perform hand hygiene before touching the line. -Use a checklist during the insertion of the central line. -Drape the patient head to toe with a sterile barrier prior to line insertion. -Everyone in the room during the insertion procedure should wear a mask. Rationale: CRBSI principles of care for insertion of a central line include performing hand hygiene before touching the line; using a checklist during the insertion of the central line; draping the patient head to toe with a sterile barrier prior to the line insertion; and having all personnel, including the patient, wear a mask during the placement of the central line. The site should be disinfected with chlorhexidine, not alcohol.

What is a possible initial complication of a patient receiving an intravenous infusion of a drug with a pH of 3 and an osmolarity of 500 mOsm/L through a short peripheral catheter?

-Phlebitis Rationale: For a short peripheral catheter, the pH of the intravenous infusion should be between 5 and 9 and the osmolarity should be between 270 to 300 mOsm/L. Infusions of a low pH and high osmolarity may cause chemical injury, which leads to vein irritation and phlebitis. Infiltration is the leakage of non-vesicants into surrounding tissues. Ecchymosis is caused by infiltration of blood into the surrounding tissues. Thrombosis is the formation of a blood clot caused by vein inflammation, not irritation.

A severely dehydrated patient requires a rapid infusion of normal saline and needs a midline IV placed. Which staff member does the emergency department (ED) charge nurse assign to complete this task?

-RN with certified registered nurse infusion (CRNI) certification who is assigned to the ED for the day Rationale: The nurse with CRNI certification is most likely to be able to quickly insert a midline catheter for a patient who is dehydrated. The chemotherapy nurse and the ED nurse have the appropriate scope of practice, but will not be as skilled in inserting a midline IV catheter. The medical-surgical nurse may be skilled at inserting short peripheral catheters, but will not be skilled in inserting midline IV catheters.

Which cadre of nurses is trained and certified in administering infusion therapy?

-Registered nurse (RN) Rationale: An RN is trained in the skill of administering peripheral IVs and is also ultimately accountable for all aspects of infusion therapy and its associated tasks. The Infusion Nurses Certification Corporation (INCC) conducts a certifying examination. Nurses who successfully complete the examination along with mastering the skills may use the initials CRNI (certified registered nurse infusion). LPNs, LVNs, and laboratory technicians may also be trained in the skill of peripheral IV insertion and infusion therapy, depending on each state's nurse practice act.

The primary health care provider instructs the nurse to change the dressing of a patient's catheter insertion site. Which action made by the nurse would lead to the dislodgement of the catheter?

-Removing the dressing by pulling it away from the insertion site Rationale: The nurse should not remove the dressing by pulling it away from the insertion site because it may lead to dislodgement of the catheter. When changing the dressing, remove it by pulling laterally from side to side. It can also be removed by holding the external catheter and pulling it off toward the insertion site.

What action should the nurse take if the patient reports unusual pain during catheter use at the caval-atrial junction (CAJ)?

-Repeat the chest x-ray. Rationale: If the patient reports unusual pain, a chest x-ray should be repeated to check the position of the catheter. The patient will not experience pain unless there is a complication with the catheter. Pain is normal at the time of insertion. If the patient reports pain after insertion, instead of reassuring the patient, the position of catheter should be checked for improper positioning and reinsertion should be performed. If a sterile catheter is not used, then infection may occur after the insertion. However, unusual pain is not associated with infection at the injection site.

Which statement is true about the special needs of older adults receiving IV therapy?

-Skin integrity can be compromised easily by the application of tape or dressings. Rationale: 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 patient's vein. Clipping the hair around the insertion site typically is necessary only for younger men.

Which statement accurately describes hypodermoclysis?

-Slow infusion of isotonic fluids into the subcutaneous tissues Rationale: Subcutaneous infusion therapy is also known as hypodermoclysis (clysis), which involves a slow infusion of isotonic fluids into subcutaneous tissues. Rapid infusion of isotonic fluids and slow or rapid infusion of hypotonic fluids do not match the description of hypodermoclysis.

A 70-year-old patient with severe dehydration is ordered an infusion of an isotonic solution at 250 mL/hr through a midline IV catheter. After 2 hours, the nurse notes that the patient has crackles throughout all lung fields. Which action does the nurse take first?

-Slow the rate of the IV infusion. Rationale: The presence of crackles throughout the lungs is a sign of possible fluid overload [1] [2]. The nurse should slow the rate of infusion and further assess for indicators of volume overload and/or respiratory distress. Assessing the site, having the patient cough and deep-breathe, and notifying the provider may be appropriate, but are not the initial actions for this patient.

When flushing a patient's central line with normal saline, the nurse feels resistance. Which action does the nurse take first?

-Stop flushing and try to aspirate blood from the line. Rationale: 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. 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 patient's circulation.

Which nursing intervention is the most appropriate when meeting resistance during the flushing of a peripheral catheter?

-Stop flushing the catheter. Rationale: When meeting resistance while flushing a catheter, the procedure should be stopped immediately. Continuing to apply pressure while flushing a catheter with resistance can result in a ruptured catheter or forcing a blood clot into the circulation. Assessing the IV line for kinks, assessing for blood return, and repositioning the extremity the catheter where the catheter is will not alter the patency of the catheter.

The nurse assessing a patient's peripheral IV site obtains and documents information about it. Which assessment data indicate the need for immediate nursing intervention?

-The vein feels hard and cordlike above the insertion site. Rationale: A hard, cordlike vein suggests phlebitis at the IV site. 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 72-96 hours.

A patient receiving intravenous therapy has developed a swollen extremity and engorged peripheral veins of the ipsilateral chest. Which complication should the nurse suspect?

-Thrombosis Rationale: A swollen extremity and engorged peripheral veins of the ipsilateral chest indicate that the patient has developed thrombosis [1] [2] as a complication of intravenous therapy. Phlebitis may cause redness and inflammation of the vein. Nerve damage is characterized by tingling or numbness at the insertion site. Blanching of the skin, tenderness, and blistering are the signs of extravasation.

How will the nurse document the intravenous (IV) therapy complication of a blood clot inside the vein?

-Thrombosis Rationale: A thrombosis is a blood clot inside the vein, a potential complication of IV therapy. Phlebitis is inflammation of the vein. Extravasation is the leakage of the IV fluid into extravascular tissue. Thrombophlebitis is inflammation and a blood clot in the vein.

A patient reports blistering, sloughing, and tissue necrosis from the site after an IV drug infusion. Which drug is likely to have caused this condition?

-Vinblastine Rationale: IV infusion of drugs, such as vinblastine and dopamine, may damage the body's tissue, resulting in tissue integrity impairment, which is manifested by blistering, sloughing, and necrosis. IV administration of venous irritant drugs, such as vancomycin, amiodarone, and ciprofloxacin, may result in phlebitis.

Which are classifications of infusion therapy solutions? Select all that apply.

-pH -Tonicity Rationale: Infusion therapy solutions are classified by pH and tonicity. Plasma, osmolarity, and electrolytes are not included in the classification of fluids used for infusion.