IV and Central Lines
A nurse is monitoring a client who is receiving an intravenous (IV) infusion of normal saline. What is a serious complication of IV therapy? 1 Bleeding at the infusion site Correct2 Shortness of breath with crackles 3 Feeling of warmth throughout the body 4 Infiltration at the catheter insertion site
Hypervolemia may precipitate pulmonary edema, which produces shortness of breath, crackles, cough, apprehension, and frothy sputum. Although bleeding at the infusion site may occur, it is not the most serious complication; an altered respiratory status is the priority. Feeling of warmth throughout the body occurs with the IV administration of dye for diagnostic procedures; it does not occur with IV fluids, such as 0.9% sodium chloride (NaCl) or D5W without an additive. Although infiltration at the catheter insertion site may occur, it is not the most serious complication; an altered respiratory status is the priority.
The nurse is caring for a client with diabetes mellitus who is scheduled to receive an intravenous (IV) administration of 25 units of insulin in 250 mL normal saline. What does the nurse recognize as the only type of insulin that is compatible with intravenous solutions? 1 NPH insulin 2 Insulin lispro Correct3 Regular insulin Incorrect4 Insulin glargine
Regular insulin acts rapidly, is approved for IV administration, and is compatible with intravenous solutions. Insulin lispro is not compatible with intravenous solutions; it is a rapid-acting insulin. Insulin glargine is not compatible with intravenous solutions; it is a long-acting insulin. NPH insulin is not compatible with intravenous solutions; it is an intermediate-acting insulin.
The nurse is providing treatment to a client for the leakage of a vesicant intravenous solution into the extravascular tissue via the short peripheral catheter. What is the most important nursing priority after the nurse has stopped the infusion and disconnected administration set? 1 The nurse should photograph the site. Incorrect2 The nurse should administer the antidote. Correct3 The nurse should aspirate the drug from a short peripheral catheter. 4 The nurse should apply cold compresses for all drugs except vinca alkaloids and epipodophyllotoxins
The most important step after the nurse has stopped the infusion and disconnected the administration set is to aspirate the drug from the short peripheral catheter. The nurse should photograph the site after applying cold compress. The next most important step after the stopping the infusion process is the administration of the antidote. After the administration of the antidote, apply a cold compress. The nurse should use a cold compress for all drugs except vinca alkaloids and epipodophyllotoxins.
To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse should change the administration set how often? Every 4 to 8 hours Every 12 to 24 hours Every 24 to 48 hours Every 72 to 96 hours
Best practice guidelines recommend replacing administration sets no more frequently than 72 to 96 hours after initiation of use in clients not receiving blood, blood products, or fat emulsions. This evidence-based practice is safe and cost effective. Changing the administration set every 4 to 48 hours is not a cost-effective practice.
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? 1 Get an additional IV infusion pump for the medication. Correct2 Check the compatibility of the medication and the continuous IV solution. 3 Disconnect the continuous IV solution while administering the piggyback medication. 4 Flush the client's venous access device to ensure patency
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
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? 1 Grade 1 Correct2 Grade 2 3 Grade 3 4 Grade 4
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.Test-Taking Tip: Come to your test prep with a positive attitude about yourself, your nursing knowledge, and your test-taking abilities. A positive attitude is achieved through self-confidence gained by effective study. This means (a) answering questions (assessment), (b) organizing study time (planning), (c) reading and further study (implementation), and (d) answering questions (evaluation).
While caring for a client receiving blood transfusion care, the nurse notices that the client is having an acute hemolytic reaction. What is the priority nursing intervention in this situation? Correct1 Stop the blood transfusion immediately. 2 Report to the primary healthcare provider. 3 Recheck identifying tags and numbers on the client. 4 Maintain a patent intravenous (IV) line with saline solution.
An incompatible blood transfusion can result in an acute hemolytic reaction in the client. During acute hemolytic reactions, the nurse should stop a blood transfusion as a priority nursing intervention. After stopping the blood transfusion, the nurse should report it to the primary healthcare provider. The nurse can then recheck the client's identifying tags and numbers and maintain a patent IV line with saline solution.
After flushing a client's left forearm saline lock (SL) with normal saline, the client begins to report a painful and burning sensation at the insertion site. Which is the most appropriate action for the nurse to take? Correct1 Remove the angiocatheter and saline lock and restart the SL in another site. 2 Document the findings per protocol and reassess the site in eight hours. 3 Flush the angiocatheter and saline lock again with sterile water. 4 Change the dressing and apply a new clean dressing.
The angiocatheter has slipped out of the vein and infiltrated into the tissue and needs to be removed and restarted in another site. The nurse then needs to document the actions and follow protocol for reassessment. Flushing the angiocatheter with sterile water would only increase the pain and aggravate the infiltration site. Changing the dressing will not help infiltration.
An elderly adult suffered an injury after falling down in the washroom. The primary healthcare provider performed a surgical procedure on the client and orders a blood transfusion. A family member of the client mentions that blood transfusions are not permitted in their community. What should the nurse do in order to handle the situation? 1 The nurse should wait for the court's order to give blood to the client. 2 The nurse should proceed with the transfusion in order to save the client's life. Correct3 The nurse should inform the primary healthcare provider and not give blood to the client. 4 The nurse should explain to the family member that the client needs this transfusion.
The client or the client's family member has the right to refuse treatment and the nurse should value their beliefs and traditions. Therefore, the nurse should inform the primary healthcare provider and not perform the blood transfusion. The nurse should not wait for a court's order or explain or convince the family member to change his or her mind. The nurse should not proceed with the treatment because this may cause severe legal implications.
The nurse is treating a client for leakage of a nonvesicant intravenous (IV) solution into the extravascular tissue. In what order should the nurse treat the infiltration? Correct1.Stop infusion and remove central venous catheter. Incorrect2.Elevate the extremity. Incorrect3.Use warm or cold compresses according to the solution infiltrated. Incorrect4.Insert a new catheter in the opposite extremity. Incorrect5.Apply a sterile dressing. Incorrect6.Rate the infiltration using the INS Infiltration Scale and document the procedure. Incorrect7.Obtain a study to determine the cause of the problem.
To stop infiltration via central venous catheter, the first step of the nurse will involve stopping the infusion and removing the central venous catheter after the identification of the problem. The next step would involve application of sterile dressing if weeping from the tissue occurs. The third step for the nurse is to elevate the extremity. Next, the nurse should use warm or cold compresses according to the solution infiltrated and the organization policy. The fifth step is to insert the new catheter in the opposite extremity. The nurse should then obtain the study to determine the problem causing the infiltration. The final step of the procedure would involve the nurse rating the infiltration using the INS Infiltration Scale and document the procedure.