Infusion Therapy (Chapter 13)
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.
A
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
A
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.
A
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.
A
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 orders
A,B
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.
A,B,D
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 blood
A,B,D
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
A,C
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.
B
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.
B
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
B
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.
B
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.
C
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.
D
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
D
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
D
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.
D
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.
D
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.
D
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.
D
