Final IV exam

tunneled catheters

inserted under skin in the chest region and threaded into large vessel so the tip rests in the superior vena ceva

Intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular for approximately 24 hours to increase urine output and maintain the client's blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and coughing. For which additional signs of a complication should the nurse assess based on the previously known data?

-Crackles in the lungs

The student nurse is preparing to initiate an infusion of 5% dextrose in 0.45% normal saline (D5/45) to a patient. The student nurse understands the fluid to have which of the following effects on the patient?

-Fluid will be pulled from the intracellular space to the extracellular space.

The nurse is caring for a patient recieving fluid resuscitation for a burn sustained 4 hours ago. Which solution would the nurse anticpate being ordered to replace fluid loss?

-LR

A client who is receiving antineoplastic medication by the intravenous (IV) route complains of pain at the insertion site of the IV. The licensed practical nurse (LPN) inspects the site and notes erythema, edema and blisters present. The LPN immediately takes which priority nursing action?

-Notifies the registered nurse (RN)

A registered nurse (RN) initiated a blood transfusion to a client nearly 30 minutes ago. The client reports difficulty breathing to the licensed practical nurse (LPN-IV) who collected a meal tray. What is the first action by the LPN-IV?

-Stop the transfusion.

Magnesium range

1.5-3

examples of hypertonic solutions

10% dextrose in water, 5% dextrose in NS, 5% dextrose in .45% saline, 5% dextrose in LR

macro-

10-20 gtts/mL

Sodium range

135-145 mEq/L

Which gauge is gonna give the most amount of fluid

14 gauge

Phosphorus range

2.5-4.5

what's the best angle to start an IV

20 degrees

potassium range

3.5-5.0 mEq/L

micro-

60 gtts/mL

Calcium range

8.5-10.5 or 4.5-5.5

people at risk for circulatory overload

CHF patients

What is potassium considered?

Electrolyte

Optimal fluid and electrolyte balance occurs when:

Fluid and electrolyte intake and absorption match the fluid and electrolyte output.

The nurse is administering IV fluids to the patient and air from the IV line enters the patient's central line. The nurse will take action by placing the patient in what position?

Left lateral Trendelenburg

Causes of hematoma

Poor IV technique and cannula too large

How are fluids lost?

hemorrhage, vomiting, diarrhea, wound drainage, burns, perspiration

Things we are allowed to flush-

heparin and NS

How is passive immunity acquired?

immunizations or mom to baby

If patient is refusing blood draw what do you do?

Walk away and document refusal

Blue top tubes are used for

coagulation study

How is active immunity acquired?

contact

What is put on a specimen label

date, time it was drawn, your initials, their name and DOB

red top tubes are used for

drug levels

if potassium is out of range what should you expect

dysrhythmias and expect an order for ab ECG

if IV is not infusing how often should you check it

every 4 hours

A nurse is assessing an older adult client who is disoriented to time and place. The nurse notes that the client's eyes are sunken, the mouth is coated, the tongue has an extra longitudinal furrow, and the client's lips are cracked. The client's hand vein filling takes more than 5 seconds; tenting is apparent over the sternum; and the vital signs are BP 110/60 mm Hg, pulse 62, and respiratory rate of 12. Based on these assessment findings, which fluid or electrolyte imbalance should the nurse suspect?

fluid volume deficient

grey top tubes are used for

glucose testing

infiltration is caused by....

leaking of a non-vesicant fluid

extravasation is caused by....

leaking of a vesicant fluid

white top tubes are used for

molecular diagnostic testing

5 rights

name, drug, dose, route, time

how long can the lancet be when doing a heel stick

no longer than 2mm

are we allowed to flush PIV and pic lines

only if a PRN adapter is in place

Implanted venous access devices

placed under the skin without any portion of it exiting the skin. It has a single or double injection port with a self sealing silicone septum covering a metal or plastic reservoir called the body. Used to administer medication, deliver fluids, and draw blood samples.

green or grey top tubes are used for

plasma chemistry

What to monitor for if sodium is low

seizures

The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of the scope of nursing practice?

-establishing the duration of the infusion

A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The licensed practical nurse (LPN) inspects the site and determines that the client has developed phlebitis. The LPN should plan to avoid which action in the care of this client?

-Prepare to start a new line in a proximal portion of the same vein.

Examples of isotonic solutions

0.9% NS, 5% dextrose in water, LR

The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action?

-Tighten the roller clamp to stop the infusion.

The RN is teaching a new LPN about hypertonic IV solutions. Further teaching is indicated when the LPN states which patient could get a hypertonic solution?

-A patient with a blood pressure of 150/90.

The nurse caring for a patient with overhydration understands the physiological effect on the body to be which of the following?

-An increase of blood volume

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the distal end of the IV tubing to a needleless device, the tubing drops and hits the top of the medication cart. Which is the appropriate action by the nurse?

-Change the IV tubing.

When your hanging IV dextrose what should you watch for

- compatibility

To prevent fluid overload what do you monitor

- intake and output, daily weight, assess for edema and crackles

Patient has blood transfusion and is having reactions what will you see

- itchiness, chest pain and shortness of breath.

A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate?

-"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."

red, black or gold top tubes are used for

serum/ chemistry

S/S of air embolism

- chest pain, SOB

A elderly patient has pulmonary edema from too rapid of an IV infusion. Which symptoms would they be exhibiting?

-Cough, dyspnea, restlessness and crackles.

The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the side rail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which action is most appropriate?

-Remove the IV catheter and reinsert another in a different location.

What will the nurse document following IV insertion?

-The number of attempts required to insert the IV and how the patient tolerated the procedure

examples of hypotonic solutions

.45% NS

A patient has an IV infusing at 75mL/hr with a hypertonic solution. The student nurse understands the effects of this type of fluid will cause the blood pressure to:

increase

The nurse is caring for a patient receiving IV antibiotic therapy every 6 hours. The IV pump frequently alarms "nonfunctional" but it clears and pumps as programmed when the reset button is pushed. Which action would the nurse take?

-Remove the pump from service and return it to biomedical engineering.

In an assessment of a patient who has a central line. The nurse finds that the patient's pulse is rapid, the blood pressure is low, and the patient is complaining of shortness of breath. The nurse evaluates these signs and symptoms as associated with:

-air embolism

A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status?

-daily weights

The nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. The nurse understands the best way to prevent a complication is to check the IV sites of these clients at which time interval?

-every hour

A student is learning how to administer intravenous fluids, including accessing a vein. What is the most potentially harmful risk posed for the client when accessing the vein?

-infection

A nurse assessing the IV site of a patient observes swelling and pallor around the site and notes a significant decrease in the flow rate. The patient complains of coldness around the infusion site. What IV complication does this describe?

-infiltration

PICC line

inserted into the basilic or cephalic vein of the arm. The end of the catheter rests in the superior vena cava just above the right atrium. PICC can have single or multiple lumens. They are intended for clients who require therapy for several days to months. They are indicated for administering fluids, bloods, and medications, as well as blood sampling

Which statement is true regarding central line dressing changes?

-"The LPN should wear sterile gloves to cleanse the site and to apply the new dressing."

A nurse is preparing to initiate I.V. therapy on a client admitted with dehydration. Which antiseptic agents are acceptable, for the nurse to use prior to cannulation, according to the Infusion Nurses Society's Standards of Practice, to cleanse the client's skin? (Select all that apply.)

-70% isopropyl alcohol -Chlorhexidine/alcohol

A client with renal disease requires IV fluids. It is important for the nurse to:

-place the fluids on an electronic device.

Which medications would predispose a patient to a hematoma?

-warfarin, aspirin, enoxaparin

A client receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at the IV insertion site. On data collection, the nurse detects coolness and swelling at the site and notes that the IV rate has slowed. The nurse determines that which has occurred?

infiltration

The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. Based on these findings, the nurse plans to take which initial nursing action?

remove the IV

what will you do if a blood transfusion reaction occurs

stop the infusion

evacuated tubes have premeasured amounts of vacuum true or false

true

Non-tunneled CVADS

used short termly

lavender or pink top tubes are used for

whole blood hematology

Are you allowed to provide nasopharyngeal suctioning

yes

if a solution is infused over an hour should you use a pump

yes anything over an hour

Are you allowed to mix antibiotics in a solution

yes if it's within scope of practice