IV therapy

The nurse is administering the first dose of an intravenous infusion of an antibiotic. Which statement made by the client is cause for concern?

"I feel like my back and arms are itching."

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."

A nursing instructor explains to students that the intravenous route of medication administration is the most dangerous. A student asks why. How would the nurse respond?

"Its effects are most immediate."

The nurse has finished teaching a client about medications that have been ordered for administration. Which client statement reflects that teaching about a piggyback infusion has been successful?

"You will give me that medication in tandem with my other IV solution."

The nursing instructor is talking with her nursing class about fluid and electrolyte balance. What would the instructor tell her students is the average daily fluid intake for an adult?

2,500 mL

A nurse is placing an IV in a newly admitted 30-year-old man. Which size catheter (lumen size and length, respectively) is most appropriate?

20 gauge, 1 inch

A nurse is administering an intermittent secondary infusion to a client. How long before administration should the nurse remove a refrigerated secondary solution?

30 minutes

Before venipuncture, the injection site should be scrubbed with Chlorhexidine antiseptic that is allowed to remain with the skin for a minimum of:

30 seconds

The nurse is caring for four clients who have just been admitted to the emergency department. Which client is likely to require intravenous medication administration, and thus needs to be seen first?

49-year-old who cut self accidentally with kitchen knife while paring potato

Which of the following IV dextrose fluids is considered isotonic in the bag?

5%

Which of the following fluids should be administered slowly to prevent circulatory overload?

5% NaCl

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?

An infant age 4 months

The nurse assesses a patient receiving IV therapy and suspects fluid overload. Which of the following assessments is most important for the nurse to perform?

Assess lung sounds for crackles or rales

Which of the following is not true of hypertonic fluid?

Causes fluid to invade the cell

A client who was involved in an accident is bleeding very heavily. Which of the following would be required to replace the circulating blood?

Colloid solution

An IV certified LPN in Ohio can infuse the following solutions. Select all that apply:

D5W 0.9 NS LR

A nurse is caring for a client with phlebitis. The nurse notices that the client's forearm, which has the tubing, has become red and slightly warm. Which actions should the nurse perform to avoid further complications and provide relief to the client?

Discontinue the IV promptly.

Assessment of a client reveals the following findings: elevated body temperature, dry skin, low urinary output, and increased pulse rate. The client's health record indicates that he is taking diuretics. Which nursing diagnosis would be most appropriate for the client?

ECF Deficient Fluid Volume

A nurse is required to initiate IV therapy for a client. Which of the following should the nurse consider before starting the IV?

Ensure that the prescribed solution is clear and transparent.

Mrs. Smith tells you that she is allergic to iodine. Hydrogen Peroxide would be an acceptable solution for IV site preparation for her. True or False?

False

The nursing instructor is discussing fluid and electrolyte balance with a group of students. One of the students asks the instructor how fluids move to maintain homeostasis. The instructor formulates her response based on her knowledge that fluid homeostasis can be maintained by which of the following? Select all that apply.

Filtration Active transport Osmosis Diffusion

A client has a saline lock (medication lock) in place in her left forearm. The client had been receiving normal saline at 75 ml per hour but this has now been discontinued, as the client is drinking well. There is an order for IV administration of an antibiotic and the nurse must now access the client's saline lock. What guideline should the nurse follow when planning when to flush the client's saline lock?

Flush before administering the drug and after administering the drug.

Which of the following solutions is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?

Isotonic

Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate?

Limit sodium and water intake.

Which vein is located on the dorsal surface of the hand?

Metacarpal

Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality?

Na+

Which of the following systems may reduce the evidence of needle stick injuries?

Needleless systems

Prior to the administration of an IV medication, a nurse has attempted to flush a client's saline lock, which has been disconnected for several hours. The nurse encounters resistance when instilling the saline solution and the client states that this causes pain in the region of the saline lock. What should the nurse do next?

Remove the saline lock and arrange for the initiation of new IV access.

A client has a physician's order for NPO (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy for what purpose?

Replace fluid and electrolytes

A nurse is preparing an intravenous infusion. Which part of the administration set would the nurse use to manually regulate the infusion rate?

Roller clamp

A nurse is assessing a client's lower arm for insertion of an IV catheter. The nurse palpates the vein and notes that it feels hard. Which action by the nurse would be most appropriate?

Select another site.

A client who has been receiving a secondary infusion of a new antibiotic for several minutes reports itching and a sensation of throat tightness. What is the priority nursing intervention?

Stop the infusion of the antibiotic.

A client is receiving a secondary infusion of a new antibiotic. After 5 minutes of administration, the client reports itching and appears flushed. What is the first nursing intervention?

Stop the infusion.

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action?

Stop the transfusion.

A woman has had her left breast removed for cancer. She also had an axillary node dissection on the left during surgery. How would this affect placement of an intravenous line?

The left arm should not be used.

. A nurse is administering an intravenous infusion of solution. The solution is supplied in a 1000 mL plastic bag. When administering this solution to the client, which of the following would the nurse need to keep in mind?

They collapse easily without the need for a vent

Appropriate actions for the nurse to take if a patient's veins do not become prominent after application of a tourniquet include all of the following except:

Tightening the tourniquet to restrict arterial flow

When the nurse is starting an intravenous infusion on a client who will be receiving multiple intravenous antibiotics, which of the following guidelines should the nurse follow?

Use distal veins before proximal veins

A nurse needs to administer 250 mL of IV solution to a client. The IV solution is packaged in a rigid glass container. Which of the following types of tubing should the nurse choose?

Vented tubing

The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy should the nurse do first?

Verify the orders for type of solution and amount of infusion.

Which of the following statements most accurately describes the process of osmosis?

Water moves through a semi-permeable membrane from an area of lower solute concentration to an area of higher solute concentration.

The tunica intima of the vein is the layer: select all that apply

With smooth endothelial lining allowing for cells and platelets to flow through without interruption. Inner most vascular layer of the vein

Accurate fluid volume assessment has been ordered for a client who has been acutely ill since the time of admission to the hospital. The nurse can best monitor this client's fluid balance by:

accurately measuring and recording the client's intake and output.

A nurse is administering a prescribed dose of medication to a client through a medication lock. How often should the nurse flush the medication lock to maintain patency?

every 8 to 12 hours

The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is:

fluid volume deficit.

The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. This assessment finding is suggestive of:

fluid volume excess.

A nurse is preparing to administer a medication by intravenous piggyback. Where will the piggyback container be placed?

higher than the primary solution container

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 client observes swelling and pallor around the site, and notes a significant decrease in the flow rate. The client reports coldness around the infusion site. What IV complication does this describe?

infiltration

A postoperative client's MAR provides for p.r.n. administration of a number of analgesics by various routes. Which route will likely provide the quickest pain relief for the client?

intravenous

Which factor is associated with rapid absorption of a drug?

intravenous route of administration

The nurse is to administer ondansetron 4 mg intravenously to a client who is reporting nausea. The client has an intermittent medication port. Ondansetron is delivered in a vial labeled 2 mg/mL. The nurse:

labels two syringes with saline and the other syringe with ondansetron 4 mg.

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

ordering type of solution, additive, amount of infusion, and duration

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?

palpating the veins on the nondominant hand

A client with dehydration is being administered IV fluids. During rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible?

phlebitis

The nursing instructor is teaching a nursing student about IV solutions. Which action by the nursing student requires the nursing instructor's intervention?

planning to use the solution one month after the expiration date

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of:

rapid fluid administration.

What would be considered a "right" of drug administration? Select all that apply.

right drug right documentation right dose right client

A student has joined the marching band at his high school. The band begins practicing outside in August. This student and other band members need to be instructed that:

the band members should drink large amounts of water.

The nurse is to administer an intravenous antibiotic to a client who is receiving a solution containing potassium chloride through the same IV tubing. To check for compatibility, the nurse first checks with:

the health care provider.

Who is responsible for maintaining the proper flow rate of the IV solution?

the nurse

nurse flushes an intravenous lock before and after administering a medication. What is the rationale for this step?

to clear medication and prevent clot formation

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:

total parenteral nutrition.

A nurse is caring for a client undergoing IV therapy. The nurse knows that intravenous administration of medication is appropriate in which situation?

when the drug needs to be administered only once