IV EXAM 2

PICC lines

central venous caths are usually placed by surgeons, although can specialized central lines be placed by specialized nurses

A charge nurse is supervising a newly licensed nurse provide care for a client who has a PCA pump. Which of the following statements made by the nurse requires further action by the charge nurse?

"I discarded the remaining 2 milligrams of morphine from the PCA pump. Please document that you witnessed it."

A nurse is teaching a client about how to use a patient-controlled analgesia (PCA) pump. Which of the following instructions should the nurse include in the teaching?

"Use the pain scale to determine if you need to self-administer."

A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make?

"Your husband should decide when more medication is needed."

macrodrip tubing

10, 15, 20 gtt/mL

A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will most likely be prescribed to increase intravascular volume, replace immediate blood loss volume, and increase blood pressure?

5% dextrose in lactated Ringer's

microdrip tubing

60 gtt/mL

A nurse is discontinuing an IV infusion. For which of the following reasons is it important to verify and document the integrity and condition of the IV catheter?

A broken-off catheter tip indicates the risk for an embolus.

A charge nurse is providing an inservice for staff nurses on the use of new IV pumps. Which of the following actions should the charge nurse take to best evaluate staff competency with the new equipment?

Allow time during the workday when each nurse can demonstrate proficiency.

Hypertonic

Are more concentrated solutions and have a higher osmolarity than body fluids, cause movement of water from cells into the extracellular fluid by osmosis (10% dextrose in water, 5% dextrose in 0.9% sodium)

Hypotonic

Cause the movement of water into cells by osmosis, rehydrates cells, should be administered slowly to prevent cellular edema (0.45% normal saline)-DILUTES EXTRACELLULAR FLUID AND REHYDRATES CELLS

Which of the following items should be written on the label of an IV bag containing medication? Select all that apply.

Client identification information. Name of the fluid infusing. Name and dosage of the medication added to the bag.

The purpose of a PCA is to allow the:

Client to regulate the timing of pain medication received.

A provider writes the following order: Infuse D5W at 125 mL/hr. The provider wants the IV to run:

Continuously

A client in early stage renal failure is prescribed an infusion of 0.45% sodium chloride. This type of solution is appropriate because it:

Dilutes extracellular fluid and rehydrates the cells.

5% Dextrose in 0.45% sodium chloride (normal saline) ; (D5W/1/2NS) are considered what type of intravenous solution?

Hypertonic

A nurse is monitoring the status of a client's fat emulsion (lipid) infusion and notes that the infusion is 1 hour behind. Which of the following actions by the nurse is appropriate?

Ensure that the fat emulsion infusion rate is infusing at the prescribed rate.

Identify the necessary components of an IV label

FLUIDS: pt identification, name of fluid, name and dosage of additives or meds, flow rate, date & time TUBING: date andn time, expiration date and time, INITIALS

Colloid

Increase the vascular volume rapidly, such as in hemorrhage or severe hypovolemia, pull excess fluid from the cells and surrounding tissue into the blood stream. Prescribed for clients who are bleeding when blood products are not immediately available

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client's IV site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which complication has occurred?

Infiltration

Select all true statements below:

Infusion pumps can overcome a slight resistance to flow, unlike drip controllers. A danger of the infusion pump is that it can infuse fluids into the tissue surrounding the vessel, causing tissue damage. The client's IV site should be inspected at least every four hours for redness, swelling, or leaking.

Lactated Ringer's(LR) is a

Isotonic solution

Which of the following statements shows an advantage of a manual gravity flow IV?

It does not require any equipment or electricity.

A nurse has just inserted a peripheral IV catheter for a continuous infusion. To secure the catheter, the nurse should:

Leave the connection between the hub and the tubing uncovered.

A nurse initiating a peripheral IV infusion punctures the skin selected vein and observes blood return in the flashback chamber of the IV catheter. Which of the following actions should the nurse perform next?

Lower the catheter until it is almost flush with the skin.

The nurse is preparing a continuous intravenous infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action?

Obtain new IV tubing.

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. After taking appropriate steps to care for the client, the nurse should document in the medical record that the client experienced which condition?

Phlebitis of the vein.

The nurse would clarify an order for a hypotonic solution prescribed for which of the following clients? Select all that apply.

Post neurosurgery head trauma increased intracranial pressure form stroke serum sodium level of 137 Hypotonic solutions are contraindicated in any client where cellular enlargement (swelling) will be traumatic, because they cause a fluid shift from blood vessels into cells. hypotonic is for hypernatremia CONTRAINDICATED in swelling because they cause a fluid shift from blood vessels into cells

The lockout interval on a PCA is designed to:

Prevent the client from receiving too much medication in too short a period.

Colloids

Pull fluid from the interstitial compartment into the vascular compartment

A nurse is removing an IV catheter from a client whose IV infusion has been discontinued. Which of the following actions is appropriate.

Pull the catheter straight back from the insertion site.

False statements

The RN should teach the client to adjust their IV pump as needed. The RN may delegate adjustment of the IV pump to a nurse assistant.

Which of the following statements is not true regarding the nurse's responsibilities when monitoring a client with a PCA?

The nurse needs to show the client's family how to push the button of the PCA when the client is sleeping.

central venous catheter

access device that is placed into a large vessel of the body, such as the jugular vein in the neck, or the subclavian vein in the cehst

Compare and contrast crystalloid and colloid IV fluids

crystalloid - dissolved substances-treat dehydration and to correct certain electrolyte imbalances EX: 0.9% sodium chloride solution (NORMAL SALINE) 0.45% SODIUM CHLORIDE SOLUTION 5% Dextrose solution 5% dextrose in 0.45% sodium chloride 10% dextrose Ringer's lactate Plasma Lyte R colloid - large- undissolved substances such as proteins, carbos, fats, or gelatin- pts who are bleeding, protein deficiencies that cause severe edema PLASMA VOLUME EXPANDERS EX: 5% albumin, 25% albumin, Dextran , hetastarch

The nurse would clarify a prescription for 5% dextrose in 0.9% sodium (D5NS) in which of the following client diagnoses?

diabetic ketoacidosis

Isotonic solutions

have the same osmolarity as body fluids

Isotonic

increases extracellular fluid volume (lactated ringers, 0.9% normal saline

maintenance fluids

maintain the body's basal metabolic needs who are unable to drink fluids by mouth but are not dehydrated

A postoperative nurse is assisting a client to manage pain using a patient-controlled-analgesia (PCA) pump. The nurse's primary rationale for using PCA is to:

maintain therapeutic serum levels of the drug.

replacement fluids

replace fluid lost through bleeding, burns, diarrhea, vomitting

When capillary blood pressure exceeds colloid osmotic pressure:

water and diffusible solutes leave the capillaries and circulate into the ISF