Module 08: Intravenous Fluid Therapy
A 4-year-old child was recently admitted to the hospital with orders for an IV to be started. The nurse prepares the IV infusion and primes the tubing, applies a tourniquet, selects a vein in the antecubital space, releases the tourniquet, applies gloves and cleans the site with chlorhexidine, reapplies the tourniquet, performs the venipuncture, obtains a blood return, advances the 24-gauge catheter off the stylet, applies pressure above the insertion site, releases the tourniquet, connects the tubing, and begins the infusion. The nurse then secures the catheter with tape and a dressing, adjusts the flow rate, and labels the dressing. Which action made by the nurse was incorrect? A. Site selection. B. Timing of beginning the infusion. C. Use of a tourniquet. D. Use of chlorhexidine to cleanse the site. E. Use of a 24-gauge catheter. F. The nurse was correct in all actions.
a The nurse was incorrect in site selection. The foot and the forearm are acceptable sites for a child. Areas of flexion such as wrist or antecubital area should be avoided because there is an increased risk for infiltration, phlebitis, or dislodgement. A tourniquet may be used with a child. A rubber band may be used with an infant and a blood pressure cuff with an elderly person. Timing of initiating the infusion was correct. Once a blood return is obtained, the tourniquet is released, and the tubing is properly connected, the nurse should begin infusing the IV fluids to prevent clotting of the catheter. A 22- to 24-gauge catheter is used for children. Chlorhexidine is the antiseptic cleansing agent of choice.
The student nurse is preparing to initiate an IV on a 36-year-old patient who is to receive an IV infusion for fluid maintenance. At this time, surgery is unanticipated. Which size catheter should the nursing student select? A. 22-gauge. B. Butterfly needle. C. A variety of sizes because the weight of the patient is unknown. D. 24- or 26-gauge. E. 18-gauge.
a Correct A 22-gauge catheter is appropriate for an adult requiring fluid maintenance. An 18-gauge catheter would be appropriate for an adult patient scheduled for surgery or who may anticipate receiving blood products or require a rapid rate of infusion of fluids. A 24- or 26-gauge catheter may be appropriate for an older adult requiring IV medications or fluids. A butterfly needle is appropriate for an infant requiring IV fluids. The patient's age and purpose of IV insertion is significant when determining gauge of catheter to select.
A trauma patient is received in the emergency room. Which size catheter should the nurse select to initiate the IV? A. 18-gauge. B. 22- to 24-gauge. C. Butterfly needle. D. 22-gauge.
a Correct A trauma patient may require rapid infusion of fluids or blood or blood products and should receive an 18-gauge catheter. A 22-gauge catheter is appropriate for IV fluids in an adult. A 22- to 24-gauge catheter is appropriate for an older adult or child. A butterfly needle is used with infants.
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? A. Proximal to the previous IV site. B. In the foot. C. Distal to the previous IV site. D. In the antecubital fossa.
a Correct The most appropriate site would be proximal to the previous site or in the opposite extremity if possible. The foot in an adult should be avoided. Having the IV catheter located in the antecubital fossa would limit the patient's movement.
In which of the following situations would it be acceptable to allow the IV infusion (IV access) to continue? A. IV is infusing but at a slower rate than ordered. B. Redness, tenderness, and warmth and palpable cord at IV site. C. Swelling above the insertion site and cool temperature. D. IV fluid container empties with subsequent loss of IV line patency.
a Correct The nurse should check for positional change that may affect the rate, as well as the height of the IV container or kinking of tubing. Once the cause of the slower infusion rate is identified and appropriate interventions take place, the IV infusion may continue. Swelling and cool skin temperature indicate infiltration. The IV should be discontinued and restarted in another location. Swelling above the insertion site and cool temperature indicate vein inflammation or phlebitis. Clotting of the catheter can cause loss of patency. The IV should be discontinued and restarted in a new location.
At what angle should an IV catheter puncture the skin and vein during insertion in a middle-aged adult? A. 10- to 30-degree angle. B. 90-degree angle. C. 45-degree angle. D. 5- to 10-degree angle.
a Correct The skin and vein should be punctured with the catheter held at a 10- to 30-degree angle. The angle of insertion may be decreased when inserting the catheter into an elderly patient to avoid rolling the vein or puncturing through the vein. Superficial veins require a smaller angle, and deeper veins require a greater angle. A 45-degree angle may be used for administering a subcutaneous injection. A 90-degree angle may be used to administer an intramuscular injection.
Which of the following would be consistent with phlebitis? (Select all that apply.) A. Pain. B. Redness. C. Coolness. D. Numbness. E. Grade 0 on phlebitis scale.
a b Phlebitis is indicated by pain, increased skin temperature, and erythema along the path of a vein. A zero on the phlebitis scale indicates no symptoms.
The nurse is assessing the patient for signs and symptoms of fluid volume excess. Which of the following would indicate the patient is experiencing this complication and should be reported? (Select all that apply.) A. Elevated blood pressure and edema. B. Shortness of breath and crackles in lungs. C. Skin turgor good and capillary refill less than 3 seconds. D. Elevated heart rate and decreased blood pressure. E. Decreased urine output and dry mucous membranes.
a b Signs and symptoms of fluid volume excess (FVE) include crackles in lungs, shortness of breath, elevated blood pressure, and edema. Signs and symptoms of fluid volume deficit include decreased urine output, dry mucous membranes, hypotension, and tachycardia. Good skin turgor and capillary refill less than 3 seconds are normal findings.
Which of the following actions fail to follow practices of infection control, therefore placing either the nurse or patient at risk? (Select all that apply.) A. Unable to obtain a flashback of blood, the nurse withdraws the catheter and needle and reinserts it at a deeper angle. B. The nurse uses a needle when aspirating for a blood return to assess for patency. C. The nurse replaces the peripheral venous catheter and rotates the site every 96 hours or immediately when complications appear. D. The nurse does not palpate the insertion site after the skin has been cleansed.
a b The nurse should obtain a new catheter when attempting IV insertion a second time. The nurse should use the needleless system whenever possible to prevent an accidental needle stick. According to the Infusion Nurses Society, the site should be rotated based on clinical assessment indicating signs or symptoms of IV-related complications or at least every 96 hours. To avoid contaminating the clean insertion site, the nurse should refrain from touching the insertion site, even with a clean glove.
The nurse is preparing to document insertion of the IV in accordance with the health care provider's orders for normal saline at 100 mL per hour. Which of the following should the nurse include in documentation of the procedure? (Select all that apply.) A. Size and type of catheter or needle. B. Number of attempts at insertion. C. Type of fluid. D. Expected time to hang next IV bag or bottle. E. Phlebitis scale rating. F. Location of insertion site. G. When infusion was begun and at what rate. H. Patient's response.
a b c f g h The nurse should record in the nurses' notes the number of attempts for insertion, type of fluid, insertion site by vessel, flow rate, size and type of catheter or needle, and when infusion was begun. The patient's response to the procedure may also be included. The expected time to hang the next IV bag or bottle may be reported to the oncoming nursing staff but is unnecessary to include in the nurse's notes. The phlebitis and infiltration scale ratings are unnecessary on a newly inserted IV.
The nurse is informing the patient of actions that may be taken to promote venous distention. Which statement, if made by the patient, indicates further instruction is needed? (Select all that apply.) A. "I've seen other nurse's tap the vein multiple times, maybe that will work." B. "You can gently stroke the vein to make it pop up." C. "I need to keep my arm elevated for 10 to 20 minutes." D. "You'll come back in a few minutes while I keep this warm towel on my arm."
a c To promote venous distention in the patient, the nurse may place the patient's arm in a dependent position (avoid elevating the arm), and rub or stoke the patient's arm. The nurse may also apply a warm pack to the arm for 10 to 20 minutes. Heat causes vasodilatation. Gentle rubbing or stroking of the patient's arm promotes venous distention. Multiple tapping of the patient's veins should be avoided as it may cause injury to the vein, such as a hematoma, or cause venous constriction.
Which of the following situations indicates peripheral IV access could be discontinued (provided the health care provider has given the corresponding order)? (Select all that apply.) The patient: A. Is being discharged to home on oral (PO) meds. B. Receives all regularly scheduled medications by mouth and has prn orders for medications administered intravenously. C. Who has been receiving IV fluids for fluid maintenance is drinking fluids well and electrolytes are within normal limits. D. Has completed the course of IV antibiotics and the intravenous access device is unnecessary. E. Has an arm that is swollen and cool to the touch and complains of pain at the IV site. F. Is NPO until nausea is resolved. G. Has an order for normal saline at 125 mL per hour and signs of fluid volume excess are absent. H. Is complaining of pain at the IV site and there is absence of a blood return.
a c d e h Discontinuing an intravenous infusion is necessary after the prescribed amount of fluid has been infused (i.e., the patient has completed the course of IV antibiotics), when an infiltration occurs (indicated by swelling, pain, pallor, and coolness to the touch at the insertion site), if phlebitis is present (indicated by the presence of redness and pain along the vein pathway), or if the infusion catheter or needle develops a clot at its tip (evidenced by inability to flush the catheter, stopping of the flow). The nurse should make sure the IV catheter is removed before the patient leaves the hospital unless home IV therapy is part of the patient's discharge instructions. If the patient is drinking fluids well and laboratory results indicate electrolytes are within normal limits, an IV infusion for maintenance is unnecessary. The patient's complaints of pain at the IV site and an absence of a blood return may indicate that the catheter lies outside of the vein and should be removed. The patient who is nauseated and NPO requires IV fluids to prevent dehydration. The patient with orders for a continuous IV infusion, without signs of fluid volume excess, should continue to have the infusion as ordered until other indicators suggest otherwise. IV fluids may be unnecessary in a patient with sufficient oral fluid intakes; however, discontinuing peripheral IV access is unwarranted if the patient's prn medication is administered by this route.
An elderly patient is receiving 0.9% normal saline at 125 mL per hour. The nursing assistive personnel (NAP) reports the patient is complaining of feeling short of breath. The nurse determines the patient is experiencing fluid volume excess. What other symptoms would lead the nurse to this conclusion? (Select all that apply.) A. Crackles in lungs. B. Hypotension. C. Peripheral edema. D. Decreased skin turgor. E. Dyspnea.
a c e Assessment findings consistent with fluid volume excess include crackles in the lungs, peripheral edema, and dyspnea (difficulty breathing). Other symptoms may include weight gain, hypertension, distended neck veins, and possibly coughing.
Which of the following would be consistent with infiltration? (Select all that apply.) A. Cool to touch. B. Redness. C. Warm to touch. D. Pain with increasing infiltration. E. Swelling around insertion site.
a d e Symptoms of infiltration include pallor, coolness to touch, edema, and pain at the insertion site.
A patient has been receiving intravenous (IV) antibiotics and as a result has had several IV site locations. What action can the nurse take to promote venous distention in the patient? (Select all that apply.) A. Apply a warm pack to the arm for several minutes. B. Elevate the arm 10 to 30 degrees. C. Use the side of paralysis to avoid a vasoconstriction response to catheter insertion. D. Choose a site distal to the previous IV site. E. Rub or stroke the patient's arm. F. Tap the patient's veins multiple times. G. Teach the patient relaxation techniques.
a e To promote venous distention in the patient, the nurse may place the patient's arm in a dependent position (avoid elevating the arm), and rub or stoke the patient's arm. The nurse may also apply a warm pack to the arm for several minutes or apply one tourniquet on the mid-upper arm and stroke downward toward the hand. After 1 to 2 minutes, apply a second tourniquet slightly below the antecubital fossa. Heat causes vasodilation, and application of the tourniquets forces blood to distend the smaller veins. Although relaxation techniques may prevent vasoconstriction, they fail to promote venous distention. Sites distal to a previous venipuncture site and an extremity with compromised circulation such as paralysis should be avoided, because such sites increase the risk of infiltration of a newly placed IV line and excessive vessel damage. Gentle rubbing or stroking of the patient's arm promotes venous distention. Vigorous rubbing and multiple tapping of the patient's veins should be avoided. These techniques may cause injury to the vein, such as a hematoma, or cause venous constriction.
A 48-year-old man has to have his IV restarted. It is currently located in his left lower forearm. He has a history of renal failure and has a shunt located in his right arm for dialysis. Which of the following is an appropriate site for IV relocation? A. The left hand where there is a prominent hardened cordlike vein. B. The left arm, proximal to the previous IV site. C. Distal to the previous IV site on the left arm. D. The right arm. E. The right hand. F. The dorsal left wrist where the veins bifurcate. G. Either foot.
b Correct The acceptable site for relocating this patient's IV is proximal to the previous IV site of the left arm. The right upper extremity should be avoided because of the presence of the vascular (dialysis) shunt. Any time an extremity has compromised circulation such as with a dialysis shunt, mastectomy, or paralysis, the area should be avoided because these venous alterations can increase the risk of complications. Sites distal to previous venipuncture sites, sclerosed or hardened cordlike veins, and areas of venous valves or bifurcation should also be avoided. The foot is common with children but is avoided in the adult because of the danger of thrombophlebitis.
The nurse is discontinuing peripheral IV access. Which of the following steps, if performed by the nurse, requires correction? A. Explain to the patient that the affected extremity must be held still. Turn the IV roller clamp to the "off" position. Perform hand hygiene and apply clean gloves. Remove the tape securing the tubing. Remove the IV site dressing and tape while stabilizing the catheter. B. With dry gauze or an alcohol swab held over the site, apply light pressure and withdraw the catheter by using a slow, steady movement with the hub at a 10- to 30-degree angle. Apply pressure to the site for 1 to 2 seconds by using a dry, sterile gauze pad. C. Inspect the catheter for intactness. Discard used supplies. Remove and discard gloves, and perform hand hygiene. D. Instruct the patient to report any redness, pain, drainage, or swelling that may occur after catheter removal. Document discontinuation of the IV access device.
b Correct The catheter needle is held at a 10- to 30-degree angle for insertion, but should be removed keeping the hub parallel to the skin. Changing the angle of the catheter inside the vein could cause additional vein irritation, increasing the risk of postinfusion phlebitis. Pressure is applied to the site for 1 to 2 minutes, not seconds, to ensure hemostasis. Pressure will control bleeding and prevent hematoma formation. The gauze should be secured with tape. The patient should be instructed to report any symptoms of phlebitis because postinfusion phlebitis may occur within 48 hours after catheter removal. The nurse should document discontinuation of the IV access device, including the time the peripheral IV was discontinued, site assessment information, gauge and length of catheter removed, and condition of the catheter tip to determine that it is intact.
The nurse is preparing an IV infusion before initiating an IV. Which of the following is a correct action performed by the nurse? A. The nurse inserts the spike of the infusion tubing into the IV medication port and fills the drip chamber completely. B. After spiking the bag of IV fluids, the nurse fills the drip chamber 1/3 to 1/2 full and primes the tubing, making sure there are no bubbles. C. The nurse spikes the bag of IV fluids with the roller clamp in the "on" position and rapidly fills the drip chamber and IV tubing. D. The nurse opens the infusion set, removes the protective sheath of the insertion spike and spikes the IV bag in any available port.
b Correct The correct procedure for preparing an IV infusion before initiating an IV is as follows: The nurse opens the infusion set and places the roller clamp 2 to 5 cm (3/4 to 2 inches) below the drip chamber and moves the roller clamp to the off position. The nurse removes the protective sheath over the IV tubing port on plastic IV solution bag. The nurse removes the sheath from the insertion spike and inserts the spike into the IV bag, fills the drip chamber 1/3 to 1/2 full, and primes the infusion tubing with IV solution, making sure there are no air bubbles.
A 4-year-old child was recently admitted to the hospital and has orders for an intravenous (IV) line to be started. Which of the following is an acceptable IV insertion site for a child? A. Ventral surface of the wrist. B. The forearm. C. The antecubital space. D. The scalp.
b Correct The forearm is an acceptable site for a child. The scalp is used with infants. The antecubital space is avoided because the antecubital fossa is used for blood draws, and placement in this area limits mobility. The dorsal surface of the hand in the older adult is avoided because these patients have fragile veins, and this site may be easily bumped. Venipuncture in ventral surface of wrist is painful and has potential for nerve damage.
The nurse is performing a routine physical assessment on a patient with heart failure. The nurse finds the following data: Patient is alert and oriented, face flushed, lung sounds with rhonchi, respirations slightly labored at a rate of 28, heart rate 98, blood pressure 140 over 92, abdomen soft with bowel sounds present, clear yellow urine in bedside drainage bag of Foley catheter, and +2 edema of lower extremities. The patient has an IV of normal saline infusing at 125 mL per hour in the left forearm without redness at the IV site. The patient denies any complaints of pain. The nurse discontinues the IV, notifies the health care provider, raises the head of the bed, and monitors the patient's vital signs. Which of these nursing actions is wrong? A. Notifying the health care provider. B. Discontinuing the IV. C. Monitoring the patient's vital signs. D. Raising the head of the bed.
b Correct The patient is demonstrating signs and symptoms of fluid volume excess (FVE). The nurse should slow the rate of the IV, notify the health care provider, raise the head of the bed to facilitate breathing, and continue to monitor the patient's vital signs. The nurse should avoid discontinuing the IV unlesa s health care provider's orders are received to do so.
Which of the following would be an appropriate site for placement of an IV? A. The flaccid arm of a patient who previously experienced a cerebrovascular accident (stroke). B. The patient's nondominant forearm. C. Distal to the previous site as long as the vein does not appear red. D. The arm on the same side of a mastectomy.
b Correct The patient's nondominant forearm is preferred because an IV placed there is less likely to inhibit mobility and activities of daily living. Place the IV at the most distal site when possible. Using a distal site first allows for the use of proximal sites later if the patient would need a venipuncture site change. Avoid areas affected by pain, infections, wounds, cerebrovascular accident, paralysis, or mastectomy.
The nursing instructor has been observing nursing students initiate an IV infusion. Which action(s), if made by the nursing student, indicate(s) that further instruction is needed? (Select all that apply.) The nursing student: A. Performs hand hygiene, spikes the bag of fluids, primes the tubing removing all air bubbles, replaces the cap on the end of the tubing, applies the tourniquet and identifies an accessible vein, removes the tourniquet, applies gloves, and cleans the site in preparation for venipuncture. B. Applies the tourniquet, cleans the site, allows it to dry, performs the venipuncture, looks for blood return, advances the catheter off the stylet, applies pressure above the insertion site, connects the tubing, starts the infusion, and releases the tourniquet. C. Removes gloves to tape and apply the transparent dressing over the intravenous site. Tapes tubing to transparent dressing. D. Cleans the insertion site with chlorhexidine solution in a back-and-forth motion for 30 seconds; allows the area to dry; then, while wearing gloves, palpates the vein before inserting the catheter at a 10- to 30-degree angle.
b c d The nursing student should not palpate the prepared site before venipuncture. The nursing student should release the tourniquet right after applying pressure and before connecting the tubing. The student should keep the gloves on until the end of the procedure, after discarding used needles and supplies, when the danger of contact with body fluids is decreased. The nursing student performed the sequence correctly when preparing the IV fluids for infusion and selecting and cleansing the site in preparation for venipuncture. Additional tape should not be placed on transparent dressing. Tubing should be secured next to dressing.
Which of the following sites should be avoided for intravenous (IV) line insertion? (Select all that apply.) A. Inner arm. B. Foot of an adult. C. Site distal to a previous venipuncture site. D. Ventral surface of wrist (inner wrist). E. Dorsal surface of the hand of a middle-aged adult. F. Areas of venous bifurcation. G. Foot of a child.
b c d f The dorsal surface of the hand and inner arm are common sites for IV insertion. The dorsal surface of the hand may be avoided in the very young and very old patient because their veins are fragile and this site may be easily bumped. The use of the foot for an IV site is common with children but is contraindicated in adults because of the danger of thrombophlebitis. A site distal to a previous venipuncture site should be avoided because there is an increased risk of infiltration of the newly placed IV line and excessive vessel damage. The inner wrist should be avoided because it has numerous tendons and nerves that could easily be damaged. Areas of venous valves or bifurcation should be avoided because they will impair insertion, create occlusion for infusion, and increase the risk of vessel damage.
1. The nurse notices failure of flow in the drip chamber with the roller clamp open and an absence of swelling at the insertion site. What should the nurse do? (Select all that apply.) A. Attempt forceful flushing to achieve catheter patency without having to relocate the IV. B. Check for kinking of IV tubing. C. Apply a warm pack to the IV site. D. Determine patency by aspirating for a blood return. E. Inject heparin flush solution into the nearest port of the catheter.
b d The nurse should first determine if the IV tubing is kinked or the patient is lying on the tubing. The nurse should determine patency of the IV catheter by aspirating for a blood return. The catheter may be occluded or positional. The nurse should never forcefully flush an intravenous catheter. Forceful flush against an occlusion such as fibrin formation, medication precipitate, or a blood clot can cause fracture of the catheter and possible embolization.
1. Which of the following sites should be avoided when initiating an intravenous infusion? (Select all that apply.) A. The foot of a child. B. Side of paralysis. C. Site proximal to a previous venipuncture site. D. The left arm of a patient who has a history of a left-sided mastectomy. E. An area of venous bifurcation or palpation of valves. F. Inner arm.
b d e Sites that should be avoided for initiating a peripheral intravenous infusion include sites distal to a previous venipuncture site, sclerosed or hardened cordlike veins, infiltrated sites or phlebotic vessels, bruised areas, and areas of venous valves or bifurcation. Veins in the antecubital fossa and ventral surface of the wrist should be avoided.
Which are hypertonic solutions used carefully in patients at risk for fluid overload because it pulls fluid into the vascular space? (Select all that apply.) A. 0.9% NaCl B. D51/2 NS C. LR D. 0.45% NaCl E. D5W F. D5LR
b f In general, isotonic fluids (i.e., 0.9% NaCl, 5% dextrose in water [D5W], lactated Ringer's [LR]) are used most commonly for extracellular volume replacement (e.g., fluid volume deficit after prolonged vomiting). The decision to use a hypotonic or hypertonic solution is based on the specific fluid and electrolyte imbalance. For example, the patient with a hypertonic fluid imbalance will generally receive a hypotonic IV solution (e.g., to dilute the extracellular fluid and rehydrate the cells). All IV solutions should be given carefully, especially hypertonic solutions, because these pull fluid into the vascular space by osmosis, resulting in an increased vascular volume that can lead to pulmonary edema, particularly in patients with heart or renal failure.
1. Upon discontinuing peripheral intravenous access, the nurse notes the catheter tip is missing. What action should the nurse take? A. Apply ice to the insertion site. B. Cover the site with a pressure dressing. C. Notify the health care provider immediately. D. Apply a warm compress to the extremity.
c Correct If the catheter tip is missing, the health care provider should be notified immediately because the broken tip can cause an embolus and an emergency situation. Applying a pressure bandage or ice is appropriate action to slow bleeding with a hematoma. A warm, compress would be applied to relieve phlebitis.
The nurse is preparing the IV for infusion. The nurse has checked the IV solution using the six rights of medication administration. The nurse checked the solution for clarity and expiration date. Which of the following steps, if performed by the nurse, require correction? A. Without touching the spike, the nurse inserts it into the tubing port of the IV and primes the infusion tubing with IV solution. B. The nurse removes the protective sheath over the IV tubing port on the IV bag and on the insertion spike of the tubing. Incorrect C. The nurse checks the length of tubing and the drip chamber to make sure that both are filled with fluid and that no air is remaining. D. The nurse opens the infusion set and moves the roller clamp 1 to 2 inches below the drip chamber and moves it to the "off" position.
c Correct The drip chamber should only be filled 1/3 to 1/2 full to be able to see the drops and determine that it is running at the appropriate rate. The other actions were performed correctly.
Which of the following situations indicates discontinuation of peripheral intravenous (IV) access? (Select all that apply.) A. The patient is drinking fluids well postoperatively and has an order for morphine IV every 3 hours as needed. B. The health care provider has ordered normal saline at 100 mL per hour and the patient's bag of IV fluids is empty. C. The patient's arm is swollen and cool to the touch; the patient complains of pain at the IV site. D. The electronic infusion pump keeps alarming, indicating "occlusion" on its screen, and the nurse is unable to flush the IV. E. The patient is being discharged to home on oral (PO) medications.
c d e Discontinuing an intravenous infusion is necessary after the prescribed amount of fluid has been infused (i.e., the patient is going home on PO medications), when an infiltration occurs (indicated by swelling, pain, pallor, and coolness to the touch at the insertion site), if bacterial phlebitis is present (indicated by the presence of redness and pain along the vein pathway), or the infusion catheter or needle develops a clot at its tip (evidenced by an inability to flush the catheter). The patient, whose bag of IV fluids is empty, with a health care provider's order for a continuous infusion, requires a new bag of IV fluids to be hung. IV fluids may be unnecessary in a patient with sufficient oral fluid intake; however, discontinuing peripheral IV access is unwarranted because this route is necessary to administer the patient's pain medication. If an occlusion occurs because of clot formation at the catheter tip, the peripheral intravenous infusion device will have to be discontinued and relocated. The nurse should first determine the presence of any kinks in the tubing or the patient lying on the tubing. The nurse may flush the catheter in an attempt to get the IV functioning properly before discontinuing the existing IV catheter.
Which are isotonic solutions most commonly used for fluid volume replacement? (Select all that apply.) A. 0.45% NaCl B. D51/2 NS C. 0.9% NaCl D. LR E. D5LR F. D5W
c d f
The student nurse is watching the staff nurse discontinue a peripheral IV. The staff nurse removes the catheter and then looks at it. The student asks the nurse what she is looking for. What would be a correct response? A. "To see if there is any clot formation on the tip." B. "To see if there is exudate at the catheter tip." C. "I'm noting the gauge of the catheter so I can document removal accurately." D. "I am inspecting the catheter for intactness."
d Clot formation may be an indication for discontinuing an IV, but the primary reason for observing the catheter tip is to determine that it is intact. The tip of the catheter can break off, causing an embolus and an emergency situation. The gauge size should be written on the dressing and recorded in the nurse's notes. Signs of infection may be an indication for discontinuing an IV.
1. Which of the following demonstrates the best documentation of discontinuation of an IV? A. 1445 21-gauge, 1-inch (2.5 cm) catheter removed from right hand. Catheter intact. Pressure applied for 5 minutes due to anticoagulant therapy. Gauze dressing and tape applied. P't states is ready to go home. L. Castello, RN. B. 1300 22-gauge 1 inch catheter removed due to complaints of pain and signs of infiltration. New 22 gauge 1 inch (2.5 cm) catheter inserted in right forearm x1 attempt. 0.45% sodium chloride infusing at 50 mL/hr without difficulty. P. Gonzalez, RN. C. 2000 IV removed and pressure applied for 2 min. Pt tolerated well. S. Chan, RN. D. 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.
d Correct 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 is the best example of documentation because the nurse documented the time the peripheral IV was discontinued, site assessment information, gauge and length of catheter removed, and condition of catheter tip to determine that it is intact. In all other samples, the documentation lacks key information about condition of the catheter tip, or site the catheter was removed from, or assessment information.
Which of the following IV solutions would be infused for the patient who has been vomiting and is requiring fluid replacement? A. D5NS B. D5LR C. 0.45% sodium chloride D. 0.9% sodium chloride
d Correct An isotonic solution, such as 0.9% normal saline, 5% dextrose in water (D5W), or lactated Ringer's (LR) is used most often to replace extracellular volume (e.g., prolonged vomiting). A hypotonic solution, such as 0.45% sodium chloride, may be used with a patient experiencing a hypertonic fluid imbalance such as with hyperosmolar hyperglycemia. The hypotonic solution will dilute the extracellular fluid and rehydrate the cells. D5LR is a hypertonic solution and may be used to pull fluid into the vascular space. D5NS is a hypertonic solution and may be used to pull fluid into the vascular space.
The nurse is preparing an IV infusion before initiating an IV. The nurse removes the protective sheath covering the tubing insertion spike and accidentally touches the spike. What is the nurse's best action at this time? A. Wipe the insertion spike with an alcohol swab, allow to dry, and insert into opening of IV bag. B. Insert spike into opening of IV bag and compress the drip chamber and release, allowing it to fill to one-half full. C. Discard IV tubing and fluids and obtain new supplies. D. Discard IV tubing and obtain a new one.
d Correct The insertion spike has been contaminated. To reduce the likelihood of infection, the nurse should discard the tubing and obtain a new one.
What is the primary danger related to a broken catheter tip? A. Pain. B. Phlebitis. C. Hematoma formation. D. Embolus. E. Infection.
d Correct The primary danger related to a broken catheter tip is an embolus. If the catheter tip is missing, the health care provider should be notified and the patient monitored.
1. When should the tourniquet be released a second time during the procedure for insertion of a peripheral intravenous device? A. After the catheter is secured with tape or a transparent dressing. B. Immediately after the catheter punctures the skin. C. Immediately after observing a "flashback" of blood in the catheter. D. After a "flashback" of blood is observed and the catheter has been advanced off the stylet.
d Correct The tourniquet is released after a "flashback" of blood is observed in the catheter's flashback chamber and the catheter has been advanced off the stylet until the catheter hub rests at the venipuncture site. Releasing the tourniquet restores blood flow to the arm. If the tourniquet is released too soon, the vein will collapse, making insertion more difficult.
Which is a hypotonic solution administered to dilute extracellular fluid and rehydrate cells? (Select all that apply.) A. 0.9% NaCl B. D51/2 NS C. D5W D. LR E. D5LR F. 0.45% NaCl
f In general, isotonic fluids (i.e., 0.9% NaCl, 5% dextrose in water [D5W], lactated Ringer's [LR]) are used most commonly for extracellular volume replacement (e.g., fluid volume deficit after prolonged vomiting). The decision to use a hypotonic or hypertonic solution is based on the specific fluid and electrolyte imbalance. For example, the patient with a hypertonic fluid imbalance will generally receive a hypotonic IV solution (e.g., to dilute the extracellular fluid and rehydrate the cells). All IV solutions should be given carefully, especially hypertonic solutions, because these pull fluid into the vascular space by osmosis, resulting in an increased vascular volume that can lead to pulmonary edema, particularly in patients with heart or renal failure.
