IVT
IV therapy should not be initiated in the following areas:
-Side of previous mastectomy -Side of previous CVA -Area affected with wound
Peripherally inserted central catheter
Inserted in antecubital space with distal end advanced into the central circulatio
What should the nurse do once she recognizes that the patient has phlebitis at his IV site?
Place a moist warm compress over the site.
An adult patient developed a complication with his IV and it had to be removed, yet continued IV fluids were needed. Which site would be most appropriate for the nurse to choose?
Proximal to the previous IV site.
hypotonic IVF
decreases intravascular compartment and increases cell size (use if fluid overload) .33%NaCl, 1/2NS
The nurse notes that the site of a client's peripheral intravenous 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? 1. Phlebitis of the vein 2. Infiltration of the IV line 3. Hypersensitivity to the IV solution 4. Allergic reaction to the IV catheter material
1. Phlebitis at an IV site can be distinguished by client discomfort at the site and by redness, warmth, and swelling proximal to the catheter. If phlebitis occurs, the nurse should discontinue the IV line and insert a new IV line at a different site.
A health care provider has written a prescription to discontinue an intravenous line. The nurse should obtain which item from the unit supply area for applying pressure to the site after removing the IV catheter? 1. Elastic wrap 2. Betadine swab 3. Adhesive bandage 4. Sterile 2 x 2 gauze
4. A dry, sterile dressing such as a sterile 2x2 is used to apply pressure to the discontinued IV site. This material is absorbent, sterile and nonirritating.
The nurse is inserting an intravenous line into a client's vein. After the initial stick, the nurse would continue to advance the catheter in which situation? 1. The catheter advances easily 2. The vein is distended under the needle 3. The client does not complain of discomfort 4. Blood return shows in the backflash chamber of the catheter.
4. The IV catheter has entered the lumen of the vein successfully when blood backflash shows in the IV catheter. The vein should have been distended by the tourniquet before the vein was cannulated. The nurse should not advance the catheter until placement in the vein is verified by blood return
The electronic infusion device (EID) alarm is sounding after changing the bag of IV fluids on a continuous infusion. What could be the possible cause(s)? (Select all that apply.) A. The roller clamp is in the "off" position. B. The drip chamber is one-third to one-half full. C. It has been 48 hours since the IV tubing was changed. D. Air is present in the tubing.
A. The roller clamp is in the "off" position. D. Air is present in the tubing.
Unexpected outcome... IV site is infiltrated
discontinue present Iv and restart new vascular access device
hypertonic IVF
expands intravascular space (decreased water, increased sodium). decreases cell size ex. D5NS, D5LR, TPN
isotonic fluids are generally given to correct this problem
fluid volume deficit
Isotonic IVF
given to expand intravascular compartment. no change in cell size ex. NS, LR, D5W
administered to rehydrate cells ... 0.45% NaCl
hypotonic solution
given carefully to renal and cardiac patients because it pulls fluid into the vascular space
Hypertonic solution
The nurse is caring for a patient who has experienced hypovolemia secondary to acute vomiting and diarrhea. The nurse anticipates what type of intravenous fluid to be ordered by the health care provider?
Hypotonic or isotonic solutions
A patient has an order for the administration of 1000 mL of 0.9% normal saline at 100 mL/hr. The nurse begins the infusion at 0900. At noon the nurse notices that 500 mL has infused. Of the following options, which should be the nurse's highest priority action?
Assess the patient for symptoms of fluid volume overload.
What should the nurse NOT do upon noting that the patient's IV site is pale, cool, and edematous?
Flush the iv site
Never given IV push, as can cause cardiac arrest
Postassium chloride
Anti-neoplastic (chemotherapy) and total parental nutrition
Vesicant
Which of the following demonstrates the best documentation of discontinuation of an IV?
1030 20 Gauge 1 inch (2.5 cm) catheter removed from left forearm. Catheter tip intact. Site without redness, swelling, or bleeding. T. Rodriguez, RN
The nurse is preparing to give a medication by IV bolus. When assessing the patient's IV insertion site, the nurse notes that it is warm, reddened, and tender. What action should the nurse take first?
Discontinue the IV infusion.
The nurse has received an order to infuse an IV medication. Which of the following would be the safest choice of equipment to use?
Smart Pump
0.9% NaCl or D5W
an isotonic solution
The nurse is caring for a patient receiving intravenous therapy. The nurse should report which of the following to the primary care provider?
Extravasation
A patient has been receiving chemotherapy via a percutaneous CVAD located in the right subclavian vein. The patient is complaining of pain and burning at the insertion site of the CVAD. The nurse notes erythema, edema, and a spongy feeling around the patient's right upper chest and neck area. Which actions would be appropriate for the nurse to take at this time? (Select all that apply.)
Stop chemotherapy administration. Administer antidote per protocol. Apply cold/warm compress.
Why do you get IV therapy?
need fluids, electrolyte imbalance, glucose, medication, decreased PO intake, and life line for emergency
A client rings the call bell and complaints of pain at the site of an intravenous infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which action in the care of this client? Select all that apply. 1. Notify the HCP 2. Remove the IV catheter at that site 3. Apply warm moist packs to the site 4. Start a new IV line in a proximal portion of the same vein 5. Document the occurrence, actions taken, and the client's response
1, 2, 3, 5 The nurse should remove the IV at the phlebitic site and apply warm moist compresses to the area to speed resolution of the inflammation. Because phlebitis occurred, the nurse also notifies the HCP about the IV complication. The nurse should restart the IV in a vein other than the one that has developed phlebitis, Finally, the nurse documents the occurrence, actions taken, and the client's response.
How often should IV fluids be changed when the order is to keep the vein open?
A) Every 24 hours Feedback: The Infusion Nurses Society (INS) recommends that each container of IV fluids be changed within 24 hours after the administration set is added. A gauze dressing of a peripheral IV site should be changed at least every 48 hours. Waiting until the fluid is in the neck of the container to change the IV fluids is inappropriate for an infusion at a KVO rate, because this would be longer than 24 hours
Which of the following indicate that the infusion needs to be temporarily discontinued, the catheter removed, and the IV relocated? (Select all that apply.) A) Patient is afebrile; absence of symptoms of infection at IV insertion site. B) Catheter is leaking at connection of hub. C) Insertion site is pale, cool to touch, and extremity edematous. D) Dried blood is present on the dressing. E) Small amount of purulent drainage is at insertion site; redness is noted. F) Patient complains of pain and tenderness along vein pathway.
C/E/F C) Insertion site is pale, cool to touch, and extremity edematous E) Small amount of purulent drainage is at insertion site; redness is noted. F) Patient complains of pain and tenderness along vein pathway. Feedback: Signs and symptoms of infiltration (i.e., insertion site pale, cool to touch, edema) or phlebitis (i.e., redness, pain and tenderness along vein pathway) require the infusion to be temporarily discontinued, the catheter removed, and the IV relocated with a new sterile catheter. Localized infection at the insertion site (redness, purulent drainage) also requires discontinuation of the present IV and relocation. It is unnecessary to relocate the IV site if the patient is afebrile and without symptoms of infection at the IV site. If the catheter is leaking, tightening the tubing and hub connection should be attempted first. Dried blood indicates the need for a dressing change but fails to require IV relocation.
Tunneled central vascular access device
Inserted first through subcutaneous tissue, then into a large vein and threaded into the distal end of the superior vena cava
Which of the following are advantages of volume-controlled intravenous infusions?
There is less risk of rapid-dose infusion (as compared with IV push) because medications are diluted and infused over longer time intervals (e.g., 30 to 60 minutes). It allows for administration of medications (e.g., antibiotics) that are stable for a limited time in solution.
A nurse takes precautions to prevent an undesirable outcome when administering medications by the intravenous (IV) route. Which of the following actions may produce an undesirable outcome? The nurse:
adds a piggyback infusion of an antibiotic to a main line IV of parenteral nutrition.
A client involved in a motor vehicle crash presents to the ED with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous solution will most likely be prescribed to increase intravascular volume, replace immediate blood loss volume, and increase blood pressure? 1. 5% dextrose in lactated Ringers 2. 0.33% sodium chloride 3. 0.225% sodium chloride 4. 0.45 % sodium chloride
1. The goal with this pt is to expand intravascular volume as fast as possible. The 5% dextrose in lactated ringers (hypertonic solution) would increase intravascular volume and immediately replace lost fluid volume until a blood transfusion could be administered, resulting in an increase in pts BP.
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? 1. Obtain a new IV bag 2. Obtain new IV tubing 3. Wipe the spike end of the tubing with Betadine 4. Scrub the spike end of the tubing with an alcohol swab
2. The nurse should obtain new IV tubing because contamination has occurred and could cause systemic infection to the client.
What is the primary danger related to a broken catheter tip?
Embolus
How often is it recommended that continuous IV infusion tubing be changed?
Every 72 hours
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? 1. Infection 2. Phlebitis 3. Infiltration 4. Thrombosis
3. An infiltrated IV has pallor, coolness and swelling resulting from the IV fluid being deposited into the subcutaneous tissue.
Identify the situations in which a peripheral IV dressing requires changing. (Select all that apply.) A. The patient's IV dressing got wet during bathing. B. It has been 48 hours since the last change of a transparent IV dressing. C. There is blood underneath the transparent dressing from movement of the catheter. D. Twenty-four hours have elapsed since the last gauze IV dressing change. E. There has been a change in the health care provider's order for the type of IV fluids.
A. The patient's IV dressing got wet during bathing C. There is blood underneath the transparent dressing from movement of the catheter
10. A nurse working in the emergency room has selected to use macrodrip IV tubing. For which patient would this be most appropriate? A) A child who has experienced nausea and vomiting for the last 24 hours B) A hypotensive adult trauma victim with cool, clammy skin C) An older adult who is being treated for congestive heart failure D) A young adult being treated for asthma with an order for D5W at 60 mL/hr
B) A hypotensive adult trauma victim with cool, clammy skin Feedback: Macrodrip tubing should be used when large quantities or fast intravenous infusion rates are necessary, as in this instance where the patient is demonstrating signs of shock. Hourly rates greater than 100 mL/hr may lend itself more to macrodrip tubing. Microdrip tubing is preferred for pediatric applications. Microdrip tubing should be used when small or very precise volumes are to be infused. Extra precautions should be made for patients at risk for fluid volume excess, such as elderly cardiac patients or renal patients.
You are going to change the dressing on your patient's PICC line when you notice that the patient's arm appears swollen and is cool to the touch. The patient has been receiving IV parenteral nutrition through the PICC line. The patient states that the IV infusion pump has been "beeping" a lot, so he kept pushing the "silence" button on the pump. You suspect extravasation. What actions should you take?
If extravasation occurs, you should first stop the infusion. You may contact the pharmacist to determine the antidote for the vesicant drug, and notify the physician. Warm compresses may also be applied to the site, and emotional support provided to the patient. The PICC line should remain in place until the physician is notified, and then only qualified staff should remove the PICC line if ordered. Blood cultures are unnecessary; they are performed if infection is suspected. The patient may be informed of the purpose of the alarm on the infusion pump; scolding the patient is inappropriate.
