IV THERAPY

A nurse is caring for a client is who has a DVT and is prescribed heparin by continuous IV infusion at 1,200 units/hr. Available is heparin 25,000 units in 500 mL D5W. The nurse should set the IV pump to deliver how many mL/hr?

24

A client is prescribed 1g potassium phosphate IV to be infused continuously over 6hr. Available is 1g potassium phosphate in 250mL dextrose 5% water. The nurse should set the Iv pump to run at how many mL/hr?

42

A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions.

Stop the infusion. Remove the IV catheter. Apply a sterile dressing. Elevate the extremity. Apply warm or cold compresses.

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client? Lactated Ringer's Dextrose 5% in 0.9% sodium chloride 0.45% sodium chloride Dextrose 10% in water

C. Lactated Ringer's This is an isotonic IV solution, which will not help correct the client's sodium elevation. Dextrose 5% in 0.9% sodium chloride This is a hypertonic IV solution, which will not help correct the client's sodium elevation. 0.45% sodium chloride A client who has an elevated sodium level and is NPO requires a hypotonic IV solution, such as 0.45% sodium chloride or 0.225% sodium chloride. Dextrose 10% in water This is a hypertonic IV solution, which will not help correct the client's sodium elevation.

A charge nurse is teaching a new nurse how to initiate IV access on a client. Which of the following actions by the new nurse indicates an understanding of the teaching? A. Shaves the selected insertion site with a razor prior to the procedure. B. Washes hands with soap and water before the procedure C. Applies sterile gloves prior to inserting the IV catheter D. Applies the tourniquet 1 inch above the selected insertion site

Washes hands with soap and water before the procedure The nurse should perform hand hygiene prior to starting the procedure.

A nurse is assessing a client who has a peripheral IV with a continuous infusion. Which of the following findings is a manifestation of phlebitis? SATA Erythema Damp dressing Throbbing Warmth at insertion site Streak formation

erythema throbbing warmth at insertion site streak formation Erythema is correct. Erythema is a reddened area at the insertion site and is a manifestation of phlebitis. Other manifestations can include throbbing, burning, and increased skin temperature. Damp dressing is incorrect. A damp dressing is a manifestation of infiltration. Other manifestations include pallor, local swelling, and decreased skin temperature. Throbbing is correct. Throbbing and pain at the insertion site are manifestations of vein inflammation and phlebitis. Warmth at insertion site is correct. Responses to inflammation include warmth and redness of the affected tissue. Streak formation is correct. Streak formation is a classic indicator of advanced phlebitis.

A nurse is calculating the intake of a client during the past 9 hr. The client's intake includes lactated Ringer's IV at 150mL.hr, cefazolin 2g IV intermittent bolus in 100 mL of 0.9% sodium chloride, two units of packed RBCs of 275 mL and 250mL; two IV bolus infusion of 250mL of 0.9% sodium chloride, famotidine 20mg IV intermittent bolus in 50mL of 0.9% sodium chloride. How many mL of intake should the nurse record?

2525 Lactated Ringer's 150 mL x 9 hr = 1,350 mL cefazolin = 100 mL packed RBCs 275 mL + 250 mL = 525 mL 0.9% sodium chloride bolus 250 mL + 250 mL = 500 ml famotidine = 50 mL Total intake = 2,525 mL

A nurse is caring for a client who had IV fluids initiated at 0330. The IV fluids are infusing at 120 mL/hr. The nurse should record how many mL of IV fluids on the intake record at 0600?

300

A nurse is preparing to infuse a 250 mL unit of packed RBCs over 2 hr. The drop factor of the manual IV tubing is 15gtts/mL. The nurse should adjust the flow rate to deliver how many drops per minute?

31 250mL x 15 gtt 120 min x 1 mL

A nurse is preparing to insert a peripheral IV catheter. Which of the following antiseptics is the nurse's best choice for preparing the client's skin at the insertion site? Alcohol Chlorhexidine Tincture of iodine Povidone-iodine

B Alcohol Although alcohol is appropriate skin preparation to help decrease peripheral IV infections, there is another antiseptic that is a better choice. Chlorhexidine Chlorhexidine is the antiseptic preferred by the Infusion Nurses Society (INS) to decrease peripheral catheter insertion site infections. Tincture of iodine Although tincture of iodine is appropriate skin preparation to help decrease peripheral IV infections, there is another antiseptic that is a better choice. Povidone-iodine Although povidone-iodine is appropriate skin preparation to help decrease peripheral IV infections, there is another antiseptic that is a better choice.

A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect? A. The client reports numbness at the site. B. Purulent drainage is noted from the site. C. The vein appears cordlike. D. Skin over the site is sloughing.

B The client reports numbness at the site. Numbness at an intravenous insertion site is a manifestation of nerve damage. Purulent drainage is noted from the site. Signs of infection include warmth, redness, swelling, and possible purulent drainage. The vein appears cordlike. Phlebitis causes a vein to become hard and cordlike. Skin over the site is sloughing. Sloughing is seen following infiltration of some medications, such as antineoplastics.

A nurse is assessing an IV infusion site on an infant's left hand. Which of the following findings should the nurse identify as an indication of an indication of an infiltration? A. Blood in the IV tubing B. Absence of blanching at the insertion site C. Edema in the palm of the hand D. Warmth around the insertion site

C Blood in the IV tubing Blood in the IV tubing can indicate disconnection of the catheter from the tubing. Absence of blanching at the insertion site Blanching at the insertion site, not absence of blanching, indicates an infiltration. Edema in the palm of the hand Edema, pallor, and coolness around the insertion site indicate a collection of fluid leaking into subcutaneous tissue, also known as an infiltration. Warmth around the insertion site An infiltration causes coolness around the insertion site. Warmth indicates phlebitis.

A nurse prepares to replace the nearly empty container of TPN for a client when she finds that there has been a delay in receiving the new container of solution from the pharmacy. Which of the following solutions should the nurse infuse until the next container of TPN solution becomes available? Lactated Ringer's 3% sodium chloride Dextrose 10% in water 0.9% sodium chloride

C Lactated Ringer's Infusing this solution would increase the client's risk for hypoglycemia. 3% sodium chloride Infusing this solution would increase the client's risk for hypoglycemia. Dextrose 10% in water Sudden withdrawal from TPN, which is a hypertonic solution that contains dextrose, vitamins, electrolytes and sometimes lipids, can result in a sudden drop in the client's blood glucose levels. Administering an infusion of 10% dextrose will prevent hypoglycemia. 0.9% sodium chloride Infusing this solution would increase the client's risk for hypoglycemia.

A nurse is administering an IM injection to a client who has hep C. Before placing the syringe and needle in a puncture-resistant container, which of the following actions should the nurse take? A. Recap the needle. B. Place the cap on the bedside table and slide the needle into the cap. C. Wrap the needle with gauze. D. Dispose of the needle uncapped.

D. Recap the needle. Recapping the needle increases the risk for a needle stick. Place the cap on the bedside table and slide the needle into the cap. Recapping the needle after use using the slider recapping method increases the risk for a needle stick. Wrap the needle with gauze. Wrapping the needle with gauze is unnecessary and increases the risk for a needle stick. Dispose of the needle uncapped. The nurse should immediately place the uncapped needle in a puncture-resistant container to prevent a needle stick with the contaminated needle.

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? A. Assess the apical pulse for a full minute. B. Assess the apical pulse with a Doppler device. C. Assess the pedal pulses for a full minute. D. Assess the pedal pulses with a Doppler device.

A Assess the apical pulse for a full minute. For clients who have a regular pulse and no cardiovascular problems, the nurse should count the apical pulsations for 30 seconds and multiply by 2. For this client, the nurse should count for 60 seconds. This will help the nurse determine the regularity or irregularity of the heart. Assess the apical pulse with a Doppler device. Unless the apical pulse site is difficult to evaluate with a stethoscope, there is no need to use a Doppler ultrasound stethoscope. Assess the pedal pulses for a full minute. Checking the pulse at other peripheral sites is not necessary, as these sites can have regular or irregular pulsations as well and will not help the nurse determine the regularity or irregularity of the heart. Assess the pedal pulses with a Doppler device. Checking the pulse at other peripheral sites with a Doppler ultrasound stethoscope is not necessary, as these sites can have regular or irregular pulsations as well and will not help the nurse determine the regularity or irregularity of the heart.

A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take? A. Remove the catheter and insert another into a different site. B. Administer an analgesic PO. C. Request a prescription for placement of a central venous access device. D. Administer a local anesthetic.

A Remove the catheter and insert another into a different site. It is possible that the catheter is up against a valve or near a nerve and is causing more pain than an IV catheter insertion should. The nurse should remove the source of the pain and establish peripheral IV access elsewhere. Administer an analgesic PO. Before administering any medication for the client's discomfort, the nurse should assess the pain and try to identify and eliminate its cause. Request a prescription for placement of a central venous access device. A central venous access device is for long-term administration of various medications and IV preparations. Outpatient surgery is not an indication for this type of IV access. Administer a local anesthetic. Before administering any medication for the client's discomfort, the nurse should assess the pain and try to identify and eliminate its cause.

A nurse is assessing an older adult client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates FVE. SATA A. Bounding pulse B. Pitting edema C. Swelling at the IV site D. Urine-specific gravity greater than 1.030 E. Crackles upon auscultation

A, B, E Bounding pulse is correct. Fluid volume excess is due to excessive fluid intake or inadequate fluid excretion. Manifestations include increased blood pressure, pulse, and respirations. With fluid volume excess, the pulse is full and bounding. Pitting edema is correct. Excess extracellular fluid can lead to pitting edema in dependent areas of the body. Swelling at the IV site is incorrect. Edema at the IV site indicates a localized accumulation of fluid due to infiltration. Although this is a concern, this finding does not suggest fluid volume excess. This finding would suggest infiltration. The nurse should discontinue the IV and restarted at another site. Urine specific gravity greater than 1.030 is incorrect. Urine-specific gravity measures the concentration of all chemical particles in the urine. A therapeutic range is 1.005 to 1.030. A urine-specific gravity greater than 1.030 indicates dehydration, and a gravity of less than 1.010 indicates fluid volume excess. Crackles upon auscultation is correct. Pulmonary edema can occur with fluid volume excess.

While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first? A. Discontinue the existing IV line. B. Initiate a new IV line in the other extremity. C. Apply a hot pack to the irritated site. D. Determine if the client needs to continue IV therapy.

A. Discontinue the existing IV line The greatest risk to the client is injury from the IV infiltration damaging soft tissues surrounding the catheter. Therefore, the first action the nurse should take is to discontinue the existing IV line. Initiate a new IV line in the other extremity. While the client will require insertion of a new IV site, this is not the first action the nurse should take. Apply a hot pack to the irritated site. While it is appropriate to apply a hot pack to the irritated site, this is not the first action the nurse should take. Determine if the client needs to continue IV therapy. Prior to reinsertion of the IV line, the nurse should clarify that the IV therapy needs to continue.

A nurse is caring for a client who is receiving TPN via a PICC. When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first? A. Measure the circumference of both upper arms. B. Notify the provider who inserted the PICC line. C. Remove the PICC line. D. Apply a cold pack to the client's upper arm.

A. Measure the circumference of both upper arms. The first action the nurse should take using the nursing process is to assess the client. The nurse should measure the arm and compare the result with the circumference of the other arm. If the arm is swollen, the nurse should notify the provider who inserted the PICC line. Swelling could indicate formation of a clot above the site or even catheter rupture. Notify the provider who inserted the PICC line. The nurse should notify the provider to prescribe removing the catheter or initiating other treatment, such as low-dose thrombolytic therapy; however, there is another action the nurse should take first. Remove the PICC line. It might become necessary to remove the PICC line, because swelling could indicate clot formation or catheter rupture; however, there is another action the nurse should take first. Apply a cold pack to the client's upper arm. It might become necessary to apply a cold pack to the client's upper arm to help relieve the edema; however, there is another action the nurse should take first.

A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds? A. The fourth heart sound (S4) B. A friction rub C. The third heart sound (S3) C. A split second heart sound S2

A. The fourth heart sound (S4) S4 is an extra sound that is heard late in diastole just before S1. It occurs due to resistance to blood flow in an enlarged ventricle. A friction rub A friction rub is a high-pitched, scratchy sound that is heard can be heard in both systole and diastole. The third heart sound (S3) S3 occurs early in diastole during filling of the ventricles. A split second heart sound S2 A split S2 heart sound results from an audible delay between the closing of the aortic and pulmonic valves.

A nurse is working with a LPN to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? A. "The infusion rate has stopped but the tubing is not kinked." B. "The area surrounding the insertion site feels warm to the touch." C. "There is fluid leaking around the insertion site." D. "There is no blood return when the tubing is aspirated."

B "The infusion rate has stopped but the tubing is not kinked." This is a sign of infiltration. "The area surrounding the insertion site feels warm to the touch." The IV fluid is at room temperature, so the area around the injection site will feel cool, not warm, to the touch when the IV is infiltrated. A warm area around the injection site indicates infection or phlebitis. "There is fluid leaking around the insertion site." This is a sign of infiltration. "There is no blood return when the tubing is aspirated." This is a sign of infiltration.

A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? BP Heart rate Urine output Weight

B. BP Fluid resuscitation is provided to prevent hypovolemia; therefore, the nurse should identify a drop in blood pressure as a need for additional fluid. Heart rate When a client's circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefore, the nurse should identify a decrease in heart rate as in indication of adequate fluid replacement. Urine output Fluid resuscitation is provided to prevent hypovolemia; therefore, the nurse should identify a drop in urine output as a need for additional fluid. Weight Fluid resuscitation is provided to prevent hypovolemia, and 1 L of water weighs about 1 kg (2.2 lb); therefore, the nurse should identify a drop in weight as a need for additional fluid.

A nurse enters an older adult client's room to insert a saline lock. The client asks the nurse, "Why do i need that? I am drinking plenty of fluids." Which of the following responses should the nurse provide? A. "It is quicker to administer medications intravenously in the hospital." B. "Clients over the age of 65 must have a saline lock according to facility policy." C. "We administer all medications intravenously to clients in this unit." D. "Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours."

D. "It is quicker to administer medications intravenously in the hospital." Rate of administration is not a factor related to whether or not a medication is given orally or parenterally. "Clients over the age of 65 must have a saline lock according to facility policy." Intravenous access is not required by facility policy according to the client's age. "We administer all medications intravenously to clients in this unit." Not all medications are available in parenteral form or need to be administered by this route.at route. "Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours." Intermittent antibiotic medications are frequently administered parenterally. This allows the client to ambulate between medication administrations, enhances client safety and promotes comfort. The response addresses the client's concern.

A nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the following veins should the nurse select? Dorsal metacarpal vein Radial vein in the wrist Antecubital vein Median vein in the forearm

D. Dorsal metacarpal vein The nurse should avoid using veins in the back of an older adult's hands, because it can limit mobility. Also, the client could easily bump the hand into objects, and older adults have less support for the area due to minimal subcutaneous tissue. Radial vein in the wrist The nurse should avoid the cephalic vein in the wrist because veins on the palmar side of the wrist lie close to the median nerve, and the venipuncture is likely to be painful and could cause nerve damage. Antecubital vein An IV site in the antecubital fossa requires immobilization of the client's elbow. An area of joint flexion is not a good choice when other sites are available. Median vein in the forearm The nurse should use the median vein in the forearm because it is distal to other potential venipuncture sites and it avoids areas of flexion. The bones in the forearm provide natural splinting and protection for IV insertion sites in the forearm and allow more freedom of movement for the client.

A nurse is attempting to flush the IV saline lock for a client. The client reports pain above the catheter site. Which of the following actions should the nurse take? A. Inject the solution more slowly while flushing the IV saline lock. B. Apply a warm compress to the IV site. C. Apply firm pressure to the plunger of the syringe during the D. IV flush to improve patency. Remove the IV saline lock.

D. Inject the solution more slowly while flushing the IV saline lock. The nurse should not inject the solution more slowly because pain above the catheter site indicates the IV is infiltrated or phlebitis is present. Apply a warm compress to the IV site. The nurse should consider applying a warm saline compress to the site to decrease swelling and pain at the IV site. Apply firm pressure to the plunger of the syringe during the IV flush to improve patency. Applying firm pressure to the plunger of the syringe during the IV flush to improve patency is contraindicated because there is indication that the IV is infiltrated or phlebitis is present. Remove the IV saline lock. The nurse should remove and move the IV catheter to another location because evidence indicates that the lock is not functioning properly.

A nurse is preparing to insert an IV catheter for a client and has selected the insertion site. Place the following steps in the order in which the nurse should perform them

cleanse with antiseptic swab, apply tourniquet/BP cuff, dilate vein, insert catheter, release tourniquet, flush catheter, secure it After the nurse first applies a tourniquet or BP cuff to help select the vein for the IV infusion, he should remove the device, cleanse the site with soap and water, allow it to dry, and then cleanse it with an antiseptic swab, again allowing it to dry. Then he should reapply the tourniquet or BP cuff, dilate the vein, check for pulsation, then insert the venous access device. After noting a blood return, he should stabilize the catheter, release the tourniquet, flush the catheter, and then secure it.