EAQ Safety and IV skills
At the start of the nursing shift, there were 200 mL in a client's intravenous (IV) bag. The nurse took the bag down when there were 50 mL still in the bag and hung a new 1000-mL IV bag. The client received two intravenous piggybacks (IVPBs) during the shift; each contained 100 mL. When calculating the intake and output at the end of the shift, the nurse looks at the IV bag. Refer to the illustration. (at the 6 mark) How many mL of IV fluid did the client receive during the shift? Record the answer as a whole number. ___ mL
950mL The client received 150 mL from the first bag, 200 mL from IVPBs, and 600 mL from the current bag. The sum of these volumes is 950 mL.
A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client?
Blood lab results Blood lab results provide objective data about fluid and electrolyte status, as well as about hemoglobin and hematocrit. Skin turgor is not a reliable indicator of hydration status for the elderly client because it is generally decreased with age. Intake and output results provide data only about fluid balance, but do not present a comprehensive picture of the client's fluid and electrolyte status; therefore this is not the best answer. The client's report about fluid intake is subjective data in general and not reliable because this client has dementia and therefore has memory problems.
A nurse is caring for a client with acute kidney injury. Which findings should the nurse anticipate when reviewing the laboratory report of the client's blood level of calcium, potassium, and creatinine? Select all that apply.
Calcium: 7.6 mg/dL (1.9 mmol/L) Potassium 6.0 mEq/L (6.0 mmol/L) Creatinine: 3.2 mg/dL (194 mcmol/L) A client with acute kidney injury will have a low calcium level, a high potassium level, and an elevated creatinine level.
A client, receiving a potassium infusion via a peripheral intravenous (IV) site, reports a burning sensation above the IV site. What should the nurse do first?
Check IV access for a blood return Because potassium infusions can be caustic to the vein, a nurse should check for continued blood return. That finding determines the nurse's next intervention(s). If blood return is present, then it is appropriate to apply warm compresses. If there is not a blood return, the infusion needs to be stopped via that IV site, not slowed. If the potassium infusion cannot be administered, the primary healthcare provider must be notified so that other means of potassium replacement can be instituted.
A nurse identifies that a client's IV site is warm, red, and tender. What does the nurse conclude is the most likely cause of this finding?
Chemical irritation to the tissues Chemical irritation to the tissues is a sign of phlebitis that can be caused by irritating medications. Rapid infusion causes fluid overload, not phlebitis. A local allergic reaction is associated with hives or a pruritic rash. Infiltration causes a pale, cool insertion site because of fluid accumulation in the tissue.
While caring for a client with an intravenous cannula, the nurse assesses the site and finds that it red, swollen, and warm with purulent drainage near the insertion site. Which nursing intervention provides client comfort?
Cleaning the site with alcohol by expressing the drainage A client with redness, swelling, and warmth with purulent drainage at the insertion site may have an infection. The nurse should clean the site immediately with alcohol and express any drainage to minimize infection. Slowing the infusion is not recommended because it may lead to a systemic spread of the infection. Elevating the extremity may help in phlebitis, with thrombosis, or with ecchymosis and hematoma. Application of cold and warm compresses may reduce the pain in a client with thrombophlebitis.
A client receiving 0.9% normal saline (NS) intravenously at keep vein open (KVO) complains of pain at the insertion site. The nurse notes that there is erythema and edema present at the access site. Based on the phlebitis scale, how should the nurse properly document the phlebitis?
Grade 2 According to the phlebitis scale, grade 2 presents as pain at the access site with erythema or edema. Grade 1 presents as erythema with or without pain. Grade 3 presents as pain at the access site with erythema or edema, streak formation, and palpable cord. Grade 4 presents as pain at the access site with erythema or edema, streak formation, palpable cord more than one inch long, and purulent drainage.
While reviewing the medical reports in an acute care setting, the nurse finds that the client is at risk for kidney damage and requests the healthcare provider to increase the intravenous fluid rate as a priority nursing intervention. Which finding supports the nurse's conclusion?
Urine output is 25 mL per hr The urine output should be at least 30 ml per hour. Less than 30 ml per hour indicates the need for notifying the healthcare provider because low urine output indicates volume depletion that may result in renal damage. Pulse pressure of 40 mm Hg is a normal finding. Systolic blood pressure of 120 mm Hg is a normal finding. Blood osmolality of 280 milliosmoles per kg is a normal finding.
A client has an IV of D5W 250 mL to which 100 mg of morphine is added. The healthcare provider prescribes 14 mg of morphine per hour for end of life palliative treatment of a client . At how many mL per hour should the nurse set the intravenous pump? Record your answer using a whole number. ___mL/hr
35ml/h
To begin the administration of total parenteral nutrition (TPN), a client has a right subclavian central venous access device inserted. Immediately after insertion of the catheter, what is the priority nursing action?
Auscultate the lungs to evaluate breath sounds The most significant and life-threatening complication of insertion of a subclavian catheter is a pneumothorax because of the proximity of the subclavian vein and the apex of the upper lobe of the lung; a client's respiratory status always is the priority. Although a chest x-ray may be done before TPN is begun, it is not the priority immediately after insertion of the catheter. A baseline blood glucose level should be obtained before insertion of the catheter. After TPN is started, routine monitoring of blood glucose levels is important. Although assessing for a neurologic deficit should be done eventually, it is not the priority at this time.
A nurse is preparing to administer an intravenous piggyback medication to a client who is receiving a continuous infusion of intravenous (IV) fluids. What is the priority nursing intervention?
Check the compatibility of the medication and the continuous IV solution Compatibility of the ordered IV medication and infusing IV solution needs to be verified to prevent harm to the client because incompatible solutions may increase, decrease, or neutralize effects of the medication. An additional IV infusion pump is not necessary because IV medication will be administered through a piggyback infusion. The nurse needs to stop IV fluids and disconnect the tubing only if the ordered IV medication is not compatible with IV fluids and there is an order to hold the continuous infusion. The client has a continuous infusion of IV; therefore patency of the IV access device is already determined
The nurse is providing postprocedure care for a client who had a central venous access device (CVAD) inserted. Before the CVAD is used, what procedure is performed to verify placement?
Chest X-Ray The insertion of a central venous catheter (CVC) into the subclavian vein can result in a pneumothorax, which would be seen on a chest x-ray. Indications of a pneumothorax before the chest x-ray would include shortness of breath and anxiety. If the chest x-ray is negative for pneumothorax, the CVC line may be used. The central line should not be flushed until placement is verified. Blood withdrawal is utilized once placement is verified, but is not used to verify initial placement. Fluoroscopy may be used during placement in certain settings, but not for placement verification.
A client is receiving total parenteral nutrition (TPN) through a central venous access device. The nurse discovers that the TPN bag is empty and the next bag has not been received yet from the pharmacy. What is the most appropriate action for the nurse to take?
Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag. Clients receiving TPN require monitoring of blood glucose because the TPN solution contains a high concentration of dextrose. In response to the high-dextrose TPN solution, the pancreas increases production of insulin to meet the glucose demands. In this situation, the current TPN infusion is completed, and the nurse should infuse 10% dextrose to compensate for the loss while the next TPN bag is being prepared. If this action is not taken, the client could experience a profound hypoglycemic reaction. After beginning an infusion of 10% dextrose, the nurse may perform a finger stick glucose test and notify the healthcare provider if the results are abnormal. Discontinuing the infusion and flushing the line until the next TPN bag is ready is not recommended. Starting an infusion of 5% dextrose at keep vein open (KVO) until the next TPN is ready may not prevent hypoglycemia; the nurse manager does not need to be involved unless there is a negative client outcome that results.
A nurse is assisting a primary healthcare provider with insertion of a central venous access catheter. Which equipment will the nurse plan to have in the room to help prepare the skin? Select all that apply.
Mask Gown Checklist Sterile gloves The primary healthcare provider who inserts the vascular access device wears sterile gloves, gown, and mask. Anyone in the room during the procedure must also wear a mask. Use a checklist during insertion to make sure everything is done correctly. Chlorhexidine is used for skin disinfection, because it has the best outcomes for preventing infection; betadine is not used.
Which personal protective equipment will the nurse wear when providing central venous access device site care?
Mask and sterile gloves A mask will protect the catheter insertion site from droplet and airborne microorganisms emanating from the nurse, and sterile gloves will protect the insertion site from contact with microorganisms on the nurse's hands. Double gloves and a hair cap are not needed. Gown use is based upon facility protocol.
A registered nurse is evaluating a new nurse who is preparing to administer intravenous fluids to a client. Which action made by the new nurse indicates the registered nurse needs to intervene?
Shaving the client's skin at the insertion site Shaving the area of injection leads to microabrasions, which can result in infections and needs to be corrected. Clipping the hair is the correct procedure. The new nurse should wash his or her hands with antibacterial soap before performing venipuncture to maintain an antiseptic environment. Chlorhexidine, a skin disinfectant, may be used at the insertion site to prevent infection and sepsis. A skin protectant solutions may be used to protect the skin and dressing and to improve the adherence of the dressing to the skin. Perry and Potter pg972
Which nursing action is necessary if nerve damage is suspected during an intravenous catheter insertion?
The nurse should immediately stop the insertion if the client reports extreme pain The nurse should immediately stop the insertion if the client reports extreme pain in case of nerve damage. The nurse should clean the exit site with alcohol. In case of venous spasm or sudden contraction of the vein, the nurse should temporarily slow the infusion rate. If the client suffers from speed shock or a systematic reaction, the nurse should immediately discontinue the drug infusion and hang isotonic solution..
A client is to receive 125 mL of intravenous (IV) fluid every hour. The drop factor of the IV tubing is 10 gtt/mL. How many drops per minute should the nurse administer? Record your answer using a whole number. ___ gtts/min
21 gtts/min
A client with a renal disorder is scheduled for an intravenous pyelogram (IVP). Which interventions should the nurse undertake prior to the procedure? Select all that apply.
Ensure the consent form is signed Assess the client for iodine sensitivity Administer an enema or cathartic (purgative/Laxative) to client The presence, position, shape, and size of kidneys, ureters, and bladder can be evaluated using an intravenous pyelogram (IVP). The contrast medium used in the procedure may cause hypersensitivity reactions. Therefore, the nurse should assess the client for sensitivity to iodine prior to the procedure. The nurse should use a cathartic or enema to empty the colon of feces and gas. An IVP does need a consent form since the procedure is invasive. The nurse has the client remove all metal objects before performing a magnetic resonance imaging (MRI) procedure. The nurse instructs the client to lie still during a computed tomographic (CT) scan procedure; during an IVP the client may be asked to turn certain ways.
The nurse is preparing to insert an intravenous catheter in a thin, emaciated client who is scheduled to begin intravenous fluid therapy. Which interventions should the nurse follow to provide high-quality care? Select all that apply.
Flush the IV line with NS Stop the insertion procedure when there is a break in technique The nurse should flush the IV line with normal saline to maintain patency. The nurse should stop the insertion procedure when there is a break in technique. This intervention helps prevent catheter-related bloodstream infections and provides high-quality care to the client. An 18-gauge needle is not an appropriate size needle to insert in a thin, emaciated client; it would cause unnecessary trauma and a high risk of phlebitis. The nurse should change the intravenous line every 72 to 96 hours to prevent the risk of infection. The nurse should avoid inserting the catheter in the client's femur because it increases the risk of bloodborne infections.
