med-surg chapter 13
A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the clients skin during this procedure?
Place a washcloth between the skin and tourniquet.
A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain?
Place warm compresses on the site.
A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?
Prepare to assist with chest tube insertion.
.A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first?
Presence of an ulnar pulse
A severely dehydrated client requires a rapid infusion of normal saline and needs a midline IV placed. Which staff member does the emergency department (ED) charge nurse assign to complete this task?
RN with certified registered nurse infusion (CRNI) certification who is assigned to the ED for the day
A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?
Report of headache and stiff neck
A nurse delegates care to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene for a client who has a vascular access device?
Use a plastic bag to cover the extremity with the device.
A client is prescribed 250 mL of normal saline to infuse over 4 hours via gravity. The facility supplies gravity tubing with a drip factor of 15 drops/mL. At what rate (drops/min) should the nurse set the infusion to deliver? (Record your answer using a whole number.)
16 drops/min
The nurse is teaching a hospitalized client who is being discharged about how to care for a peripherally inserted central catheter (PICC) line. Which client statement indicates a need for further education?
"I can continue my 20-mile running schedule as I have for the past 10 years."
The nurse is inserting a peripheral intravenous (IV) catheter. Which client statement is of greatest concern during this procedure?
"My hand tingles when you poke me."
A client who used to work as a nurse asks, "Why is the hospital using a 'fancy new IV' without a needle? That seems expensive." How does the nurse respond?
"They minimize health care workers' exposure to contaminated needles."
A 22-year-old client is seen in the emergency department (ED) with acute right lower quadrant abdominal pain, nausea, and rebound tenderness. It appears that surgery is imminent. What gauge catheter does the ED nurse choose when starting this client's intravenous solution?
18
A client is prescribed 1000 mL of normal saline to infuse over 24 hours. At what rate should the nurse set the pump (mL/hr) to deliver this infusion? (Record your answer using a whole number.) ____ mL/hr
42
A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the clients chart prior to administering the medication: Client: Thomas Jackson DOB: 5/3/1936 Gender: Male January 23 (Today): Right upper extremity PICC is intact, patent, and has a good blood return. Site clean and free from manifestations of infiltration, irritation, and infection. Sue Franks, RN January 20: Purulent drainage from sacral wound. Wound cleansed and dressing changed. Dr. Smith notified and updated on client status. New orders received for intravenous antibiotics. Sue Franks, RN January 13: Client alert and oriented. Sacral wound dressing changed. Sue Franks, RN January 6: Right upper extremity PICC inserted. No complications. Discharged with home health care. Dr. Smith
Administer the prescribed medication.
A client is being admitted to the burn unit from another hospital. The client has an intraosseous IV that was started 2 days ago, according to the client's medical record. What does the admitting nurse do first?
Anticipate an order to discontinue the intraosseous IV and start an epidural IV.
The nurse is starting a peripheral IV catheter on a recently admitted client. What actions does the nurse perform before insertion of the line? (Select all that apply.)
Apply povidone-iodine to clean skin, dry for 2 minutes. Clean the skin around the site. Prepare the skin with 70% alcohol or chlorhexidine.
A nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this clients teaching?
Ask all providers to vigorously clean the connections prior to accessing the device.
The nurse who is starting the shift finds a client with an IV that is leaking all over the bed linens. What does the nurse do initially?
Assess the insertion site.
A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this clients teaching?
Avoid carrying your grandchild with the arm that has the central catheter.
A client is admitted to the cardiothoracic surgical intensive care unit after cardiac bypass surgery. The client is still sedated on a ventilator and has an arterial catheter in the right wrist. What assessment does the nurse make to determine patency of the client's arterial line?
Capillary refill and pulse
The nurse is admitting clients to the same-day surgery unit. Which insertion site for routine peripheral venous catheters does the nurse choose most often?
Cephalic vein of the forearm
A client who is receiving intravenous antibiotic treatments every 6 hours has an intermittent IV set that was opened and begun 20 hours ago. What action does the nurse take?
Change the set in about 4 hours.
The nurse is administering a drug to a client through an implanted port. Before giving the medication, what does the nurse do to ensure safety?
Check for blood return
A nurse responds to an IV pump alarm related to increased pressure. Which action should the nurse take first?
Check for kinking of the catheter.
The nurse is documenting peripheral venous catheter insertion for a client. What does the nurse include in the note? (Select all that apply.)
Client's response to the insertion Date and time inserted Type and size of device Type of dressing applied Vein used for insertion
The nurse checking an IV fluid order questions its accuracy. What does the nurse do first?
Contacts the health care provider who ordered it
A nurse prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of heparin. The pharmacy supplies a multi-dose vial of heparin with a concentration of 100 units/mL. Which of the syringes shown below should the nurse use to draw up and administer the heparin?
D. Always use a 10-mL syringe when flushing PICC lines because a smaller syringe creates higher pressure, which could rupture the lumen of the PICC.
A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next?
Ensure an x-ray is completed to confirm placement.
The nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion?
Ensures that another qualified health care professional checks the unit before administering
A client is seen in the emergency department (ED) with pain, redness, and warmth of the right lower arm. The client was in the ED last week after an accident at work. On the day of the injury, the client was in the ED for 12 hours receiving IV fluids. On close examination, the nurse notes the presence of a palpable cord 1 inch in length and streak formation. How does the nurse classify this client's phlebitis?
Grade 3
While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?
Grade 3 phlebitis at IV site
The nurse is revising an agency's recommended central line catheter-related bloodstream infection prevention (CR-BSI) bundle. Which actions decrease the client's risk for this complication? (Select all that apply.)
Immediately removing the client's venous access device (VAD) when it is no longer needed Thorough hand hygiene (i.e., no quick scrub) before insertion Using chlorhexidine for skin disinfection
A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client?
Infection
A client is to receive an IV solution of 5% dextrose and 0.45% normal saline at 125 mL/hr. Which system provides the safest method for the nurse to accurately administer this solution?
Infusion pump
A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should the nurse suggest to the management team to make the biggest impact on decreasing complications?
Initiate a dedicated team to insert access devices.
A client admitted to the intensive care unit is expected to remain for 3 weeks. The nurse has orders to start an IV. Which vascular access device is best for this client?
Midline catheter
A client who takes corticosteroids daily for rheumatoid arthritis requires insertion of an IV catheter to receive IV antibiotics for 5 days. Which type of IV catheter does the nurse teach the new graduate nurse to use for this client?
Midline catheter
Which client does the charge nurse on a medical-surgical unit assign to the LPN/LVN?
Older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours
Which statement is true about the special needs of older adults receiving IV therapy?
Skin integrity can be compromised easily by the application of tape or dressings.
A 70-year-old client with severe dehydration is ordered an infusion of an isotonic solution at 250 mL/hr through a midline IV catheter. After 2 hours, the nurse notes that the client has crackles throughout all lung fields. Which action does the nurse take first?
Slow the rate of the IV infusion.
A registered nurse (RN) delegates client care to an experienced licensed practical nurse (LPN). Which standards should guide the RN when delegating aspects of IV therapy to the LPN? (Select all that apply.)
State Nurse Practice Act The facilitys Policies and Procedures manual
When flushing a client's central line with normal saline, the nurse feels resistance. Which action does the nurse take first?
Stop flushing and try to aspirate blood from the line.
A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?
Stop the infusion of intravenous fluids.
.A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?
The clients left lower extremity is cool to the touch.
The nurse assessing a client's peripheral IV site obtains and documents information about it. Which assessment data indicate the need for immediatenursing intervention?
The vein feels hard and cordlike above the insertion site.
A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention?
Upper extremity swelling is noted.
A nurse assists with the insertion of a central vascular access device. Which actions should the nurse ensure are completed to prevent a catheter-related bloodstream infection? (Select all that apply.)
a.Include a review for the need of the device each day in the clients plan of care. b.Remind the provider to perform hand hygiene prior to starting the procedure. d.Ask everyone in the room to wear a surgical mask during the procedure.
.A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which complications should the nurse assess? (Select all that apply.)
a.Phlebitis c.Thrombophlebitis
A nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) universal bar-coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply.)
a.Unique facility identifier b.Lot number related to the donor d.ABO group and Rh type of the donor
