IV THERAPY
A nurse is assessing a patient receiving IV normal saline at 125 mL/hr. Which of the following should the nurse recognize as a possible complication related to the intravenous therapy? a) Petechiae over the IV site. b) The skin is cool over the IV site. c) Patient reports cough and shortness of breath. d) Patient's blood pressure is lower than normal.
Answer: c) Patient reports cough and shortness of breath. Rationale: Yes. This is a sign of fluid overload. You should slow the IV and notify the provider.
Which of the following is an important nursing action when converting an IV infusion to a saline lock? a) Open the roller clamp of the primary infusion to prime the saline lock. b) Apply pressure with a syringe to clear resistance in the IV catheter. c) Attach secondary tubing to allow mobility. d) Flush the IV catheter to confirm patency.
Answer: d) Flush the IV catheter to confirm patency. Rationale: It is essential to attach the primed saline lock adapter to the extension tubing and to flush the tubing with normal saline to confirm patency.
A patient is to receive 1,000 mL of 5% dextrose in lactated Ringer's over 8 hours. Using tubing with a drop factor of 15 gtt/mL, the nurse should regulate the fluid to infuse at how many drops per minute? (Round the answer to the nearest whole number.) ____ gtt/min
Answer: 31 Rationale: A formula for determining an IV flow rate in drops per minute is: volume (mL) × drop factor (gtt/mL) = IV flow rate (gtt/min) time (min) The information from the scenario is: volume (mL) = 1,000 time (min) = 480 drop factor (gtt/mL) = 15 The flow rate (drops to infuse per minute) is determined as follows: 1,000 × 15 = x 480 Then: 15,000 = x480 Then: 31.25 = x The IV flow rate in gtt/min is 31.
A patient is to receive 1 g of ceftriaxone (Rocephin) in 100 mL over 30 min. The tubing drip rate is 10 gtt/mL. The nurse should adjust the flow rate to what infusion rate? ____ gtt/min
Answer: 33 gtt/min Rationale: To determine the correct flow rate divide the volume to be infused by the time in minutes and multiply by the drop factor. So, 100 (volume to be infused) divided by 30 (time in min) x 10 (drops per mL) = 33 gtt/min.
A nurse finds a patient's IV insertion site red, warm, and slightly edematous. Which of the following actions should the nurse perform first? a) Check for a blood return b) Elebate the extremity c) Discontinue the IV line d) Applly warm, moist heat
Answer: Discontinue the IV line Rationale: The patient has classic signs of phlebitis, an inflammation of the vein. The IV line must be discontinued immediately to reduce the risk of thrombophlebitis and embolism.
A patient was admitted to the hospital for same day surgery and has orders for continuous intravenous (IV) therapy. Before performing a venipuncture, the nurse should a) Place a cold compress over the vein. b) Inspect the IV solution for fluid color, clarity, and expiration date. c) Apply a tourniquet 1 to 2 in above selected insertion site. d) Secure an armboard to the joint.
Answer: Inspect the IV solution for fluid color, clarity, and expiration date. Rationale: All IV solutions must be free of contaminants, particles, and current for usage.
A nurse is caring for a patient who is receiving D5W with 20 mEq of KCL at 75 mL/hr. The provider has prescribed 1 g ceftriaxone (Rocephin) IV. When preparing to administer this medication by IV piggyback, which of the following data is the highest priority for the nurse to collect? a) The patient's vital signs b) The patient's level of consciousness c) The medication's compatibility with the primary IV solution d) The amount of IV solution in the primary bag
Answer: The medication's compatibility with the primary IV solution Rationale: The nurse must assess the medication's compatibility with the primary solution prior to administration. If the medication is not compatible with the primary solution, a precipitate can form in the IV tubing, preventing medication administration.
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) A broken-off catheter tip indicates the risk for an embolus. b) Catheter erosion indicates that it was left in place too long. c) Blood within the catheter could indicate clot formation. d) Discoloration of the catheter could be a sign of phlebitis.
Answer: a) A broken-off catheter tip indicates the risk for an embolus. Rationale: The tip of the catheter can break off, thus creating an embolus. To limit the movement of the embolus, the nurse should apply a tourniquet high on the extremity where the IV line was located and notify the provider immediately.
A nurse has just inserted a peripheral IV catheter for a continuous infusion. To secure the catheter, the nurse should a) leave the connection between the hub and the tubing uncovered. b) wrap tape around the circumference of the patient's arm. c) tape the IV catheter's hub securely to the patient's skin. d) place a piece of paper tape over the insertion site.
Answer: a) leave the connection between the hub and the tubing uncovered. Rationale: This makes it possible to replace the tubing without removing the dressing.
A nurse is about to administer an intravenous medication directly into the vein. The nurse should understand that a disadvantage of parenterally administered medications is that they a) are irreversible. b) have slow onset. c) bypass the liver. d) have less bioavailability.
Answer: are irreversible Rationale: Yes. Once a medication has been injected, it cannot be retrieved. If the dose is excessive or the patient is allergic, the consequences can be deadly.
A nurse initiating a peripheral IV infusion punctures the skin and selected vein and observes blood return in the flashback chamber of the IV catheter. Which of the following actions should the nurse perform next? a) Secure the catheter to the skin with a transparent dressing. b) Lower the catheter until it is almost flush with the skin. c) Advance the catheter about 1/4 inch into the vein. d) Remove the stylet slowly from the lumen of the catheter.
Answer: b) Lower the catheter until it is almost flush with the skin. Rationale: Lowering the angle and then advancing the catheter slightly facilitates full penetration of the wall of the vein, thus placing the catheter within the vein's lumen and making it easy to advance the catheter off the stylet.
A nurse administers the first dose of a patient's prescribed antibiotic via IV piggyback. During the first 10 to 15 min of administration of the medication, the nurse gives priority to which of the following assessments? a) IV site for redness or swelling b) Patient for systemic allergic reaction c) IV dressing for signs of leakage d) Limb for signs of discomfort
Answer: b) Patient for systemic allergic reaction Rationale: Yes. Patients may experience a systemic allergic reaction especially with IV antibiotics and should be observed for the first 10 to 15 min.
A patient in early stage renal failure is prescribed an infusion of 0.45% sodium chloride. This type of solution is appropriate because it a) pulls fluid from the cells and increases vascular volume. b) dilutes extracellular fluid and rehydrates the cells. c) replaces extracellular volume and maintains intravascular volume. d) draws fluid into blood vessels and reduces interstitial compartments.
Answer: b) dilutes extracellular fluid and rehydrates the cells Rationale: Infusing a hypotonic solution such as 0.45% sodium chloride moves fluid into the cells, thus enlarging and rehydrating them.
A nurse is caring for a patient with a peripherally inserted central catheters (PICC line). Which of the following is true about this type of intravenous route? a) A PICC line is a short catheter inserted into the jugular vein. b) A PICC line is a catheter that allows for infusion of intravenous fluids without an infusion pump. c) A PICC line is a long catheter inserted through the veins of the antecubital fossa. d) A PICC line is a catheter that is used for emergent or trauma situations.
Answer: c) A PICC line is a long catheter inserted through the veins of the antecubital fossa. Rationale: Yes. PICC lines have lower complication rates because they are inserted in the upper extremity.
A nurse is caring for a patient receiving 0.9% sodium chloride (normal saline) at 75 mL/hr through a triple lumen central venous catheter. The pump is alarming that there is an occlusion. Which of the following is the first thing the nurse should do? a) Call the provider who inserted the catheter. b) Flush the line with a 10-mL syringe of heparin. c) Check the line at or above the hub for kinked tubing that is creating a resistance to flow. d) Reposition the patient.
Answer: c) Check the line at or above the hub for kinked tubing that is creating a resistance to flow. Rationale: Yes. This is most likely the problem and should be where the nurse checks first.
A nurse has just initiated a peripheral IV infusion of 5% dextrose in water. How often should the nurse plan to replace the primary infusion tubing? a) Every 24 hours b) Every 48 hours c) Every 72 hours d) Every 108 hours
Answer: c) Every 72 hours Rationale: The Centers for Disease Control and Prevention recommends changing IV tubing no more often than at 72-hour intervals unless the tubing has been contaminated, punctured, or obstructed.
A nurse is removing an IV catheter from a patient whose IV infusion has been discontinued. Which of the following action is appropriate? a) apply firm pressure over the vein b) leave the roller clamp slightly open c) pull the catheter straight back from the insertion site d) lift the hub slightly upward away from the skin
Answer: c) pull the catheter straight back from the insertion site Rationale: with the catheter stabilized and using a slow, steady movement, the nurse should withdraw the catheter straight back and away from the insertion site, making sure to keep the hub parallel to the skin
A nurse who has just initiated an IV infusion explains to the patient that complications are possible and that she will monitor the infusion regularly. The nurse should teach the patient that which of the following findings is an indication of early infiltration? a) Moisture b) Bruising c) Tingling d) Coolness
Answer: d) Coolness Rationale: Coolness is a classic sign of infiltration, along with swelling, pallor, and possibly tenderness. Infiltration is a leakage of IV solution out of the intravascular compartment into the surrounding tissue.
