NCLEX: IV therapy and Blood Transfusions CH 14 & 15

Latex allergy

- Assess for allergy to latex - IV supplies (IV catheter, IV tubing, IV ports, particularly IV rubber injection ports, rubber stoppers on multidose vials, adhesive tape) may contain latex - Latex-safe IV supplies should be used if client has latex allergy - 3-way stopcock, rather than rubber injection port, needs to be used on plastic tubing

Blood Transfusion Complication: Iron overload interventions

- Deferoxamine (desferal) IV or SQ: removes accumulated iron via kidneys - urine turn red as iron excreted after administration of deferoxamine; DC when iron lvls normal

Hypertonic solutions

- More concentrated and have higher osmolality than body fluids - Cause movement of water from cells into the EC fluid (cell shrinks)

Hypotonic solutions

- More dilute and have lower osmolality than body fluids - causes movement of water into cells - Should be administered slowly to prevent cellular edema

Vented and Nonvented tubing

- a vent allows air to enter the IV container as fluid leaves - a vented adapter is used to add a vent to a nonvented IV tube - Use nonvented tubing for flexible containers - Use vented tubing for glass or rigid plastic containers to allow air to enter and displace the fluid as it leaves; fluid will not flow from a rigid IV container unless it is vented

IV Complications: Circulatory overload

- aka fluid overload - DT administration of fluids too rapidly, especially in client at risk for fluid overload

Colloids

- aka plasma expanders - pull fluid from the interstitial compartment into the vascular component - increases the vascular volume rapidly (for hemorrhage or severe hypovolemia)

Addition of Medication to an IV solution

- assess compatibility - mix the bag end over end several times before hanging to disperse meds - Manufacturer-prepared IV med systems are available; similar to a secondary IV with med or a piggyback - ensure meds can be mixed in soft plastic bc some meds absorb into soft plastic and should only be mixed in glass

Blood bank precautions

- blood only released to specified personnel - name and ID number of recipient must be provided by blood bank - blood transported from blood bank to only 1 client at a time to prevent blood delivery to wrong client

Packed red blood cells (PRBCs)

- blood product used to replace RBCs; infusion time for 1 unit usually 2-4hrs - 1 unit = 1 g/dL increase in Hgb; 3% increase in Hct; change in labs takes 4-6 hrs after completion of transfusion - Evaluation of effective response based on resolution in RBC, Hgb, Hct

Blood Transfusion Complication: Hypocalcemia

- citrate in transfused blood binds w/Ca and excreted - assess Ca lvl before and after transfusion - monitor for s/s: hyperactive reflexes, paresthesias, tetany, muscle cramps, positive Trousseau's sign, positive Chvostek's sign (hypocalcemia = hyperactive body) - slow transfusion and notify HCP if hypocalcemia occurs

Blood Transfusion Complication: Circulatory Overload s/s

- cough, dyspnea, chest pain, wheezing - headache - HTN, tachycardia and bounding pulse - distended neck veins

Blood Transfusion Complication: Disease transmission

- hepatitis C: most commonly transmitted; s/s = anorexia, NV, dark urine, jaundice; symptoms occur w/in 4-6 weeks after transfusion - other diseases = hepatitis B, HIV, herpes, Epstein-Barr virus, human T-cell leukemia, cytomegalovirus, and malaria - donor screening has greatly reduced risk of transmission (esp antibody testing donors for HIV)

Blood Transfusion Complication: Septicemia interventions

- notify HCP - obtain blood cultures and cultures of blood bag - administer O2, IV fluids, antibiotics, vasopressors, and corticosteroids

Blood Transfusion Complication: Septicemia s/s

- rapid onset of chills and high fever, vomiting, diarrhea, hypotension, shock

Blood Transfusion Complication: Circulatory Overload interventions

- slow rate of infusion*** - place upright, w/feet dependent*** - notify HCP - administer O2, diuretics, and morphine as prescribed - monitor for dysrhythmias - phlebotomy may be prescribed if severe

Blood Transfusion Complication: Hyperkalemia

- stored blood liberates K thru hemolysis - older blood = increased risk for hyperkalemia - clients w/renal insufficiency or renal failure should receive fresh blood - assess date of blood and serum K before and after transfusion - monitor for s/s: paresthesias, weakness, abdominal cramps, diarrhea, dysrhythmias) - slow transfusion and notify HCP if hyperkalemia occurs

Blood Transfusion Complication: Iron overload s/s

- vomiting, diarrhea, hypotension, altered hematological values

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item? 1. Vital signs 2. Skin color 3. Urine output 4. Latest hematocrit level

1 A change in vital signs during the transfusion from baseline may indicate that a transfusion reaction is occurring. This is why the nurse assesses vital signs before the procedure and again after the first 15 minutes. The other options do not identify assessments that are a priority just before beginning a transfusion.

The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question? 1. "Have you ever had a transfusion before?" 2. "Why do you think that you need the transfusion?" 3. "Have you ever gone into shock for any reason in the past?" 4. "Do you know the complications and risks of a transfusion?"

1 Asking the client about personal experience with transfusion therapy provides a good starting point for client teaching about this procedure. Questioning about previous history of shock and knowledge of complications and risks of transfusion are not helpful because they may elicit a fearful response from the client. Although determining whether the client knows the reason for the transfusion is important, it is not an appropriate statement in terms of eliciting information from the client regarding an understanding of the need for the transfusion

A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mmHg. The client's temperature is 100.8F orally from a baseline of 99.2F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? 1. Septicemia 2. Hyperkalemia 3. Circulatory overload 4. Delayed transfusion reaction

1 Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and he development of shock. Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. A delayed transfusion reaction can occur days to years after a transfusion. Signs include fever, mild jaundice, and a decreased hematocrit level.

The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. Which item is important to check regarding the age of blood cells before the transfusion is begun? 1. Expiration date 2. Presence of clots 3. Blood group and type 4. Blood identification number

1 The nurse notes the expiration date on the unit of blood to ensure that the blood is fresh. Blood cells begin to deteriorate over time, so safe storage usually is limited to 35 days. Careful notation of the expiration date by the nurse is an essential part of the verification process before hanging a unit of blood. The nurse also notes the blood identification(unit) number, blood group and types, and client's name. The nurse also inspects the unit of blood for leaks, abnormal color, clots, and bubbles and returns the unit to the blood bank if clots are noted.

Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement first? 1. Maintain bed rest with legs elevated 2. Place the client in high-Fowler's position 3. Increase the rate of infusion of intravenous fluids 4. Consult with the health care provider regarding initiation of oxygen therapy

2 New onset of tachycardia, bounding pulses, and crackles and wheezes posttransfusion are evidence of fluid overload, a complication associated with blood transfusion. Placing the client in a high-Fowler's (upright) position will facilitate breathing. Measures that increase blood return to the heart, such as leg elevations and administration of intravenous fluids, should be avoided at this time. In addition, administration of fluids cannot be initiated without a prescription. Consulting with the health care provider regarding administration of oxygen may be necessary, but positional changes take a short amount of time to do and should be initiated first.

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6 F orally. Which action should the nurse take? 1. Begin the transfusion as prescribed 2. Administer an antihistamine and begin the transfusion 3. Delay hanging the blood and notify the health care provider 4. Administer two tablets of acetaminophen (Tylenol) and begin the transfusion

3 If the client has a temperature higher than 100F, the unit of blood should not be hung until the HCP is notified and has the opportunity to give further prescriptions. The HCP likely will prescribe that the blood be administrated regardless of the temperature, but the decision is not within the nurse's scope of practice to make. The nurse needs an HCP's prescription to administer medication to the client.

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next? 1. Remove the intravenous (IV) line 2. Run a solution of 5% dextrose in water 3. Run normal saline at a keep-vein-open rate 4. Obtain a culture of the tip of the catheter device removed from the client

3 If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-vein-open rate pending further HCP prescriptions. This maintains a patent IV access line and aids in maintaining the client's intravascular volume. The nurse would not remove the IV line because then there would be no IV access route. Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter should not be removed. Second, cultures are performed when infection, not transfusion reaction, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump

A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias? 1. Infusion pump 2. Pulse oximeter 3. Cardiac monitor 4. Blood-warming device

4 If several units of blood are to be administered, a blood warmer should be used. Rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias. To prevent this, the nurse warms the blood with a blood-warming device. Pulse oximetry and cardiac monitoring equipment are useful for the early assessment of complications but do not reduce the occurrence of cardiac dysrhythmias. Electronic infusion devices are not helpful in this case because the infusion must be rapid, and infusion devices generally are used to control the flow rate. In addition, not all infusion devices are made to handle blood or blood products.

A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding? 1. Increased hematocrit level 2. Increased hemoglobin level 3. Decline of elevated temperature to normal 4. Decreased oozing of blood from puncture sites and gums

4 Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes. Increased hemoglobin and hematocrit levels would occur when the client has received a transfusion of red blood cells. An elevated temperature would decline to normal after infusion of granulocytes if those cells were instrumental in fighting infection in the body.

IV Complications: Electrolyte Overload

An electrolyte imbalance caused by too rapid or excessive infusion or by use of inappropriate IV solution

Blood Transfusion Complication: Circulatory Overload

caused by infusion of blood at a rate too rapid for client to tolerate

IV Complications: Catheter embolism s/s

decreased BP, pain along vein, weak rapid pulse, cyanosis of nail beds, LOC

IV Complications: Hematoma s/s

ecchymosis, immediate swelling and leakage of blood at site, hard and painful lumps at site

Blood Transfusion Complication: Septicemia

occurs w/the tranfusion of blood that is contaminated w/microbes

IV Complications: Electrolyte Overload s/s

signs depend on the specific electrolyte overload imbalance

IV Complications: Hematoma

The collection of blood in the tissues after an unsuccessful venipuncture or after the venipuncture site is discontinued and blood continues to ooze into the tissue

IV Complications: Air embolism

a bolus of air enters the vein thru inadequately primed IV line, from loose connection, during tubing change, or during removal of IV

IV Complications: Infiltration s/s

edema, pain, coolness at site, may or may not have blood return

Contraindications to an epidural catheter

skeletal and spinal abnormalities, bleeding disorders, use of anticoagulants, hx of multiple abscesses, and sepsis

IV Complications: Tissue Damage s/s

skin color changes, sloughing of skin, discomfort at site

IV Complications: Air embolism s/s

tachycardia, chest pain, dyspnea, hypotension, cyanosis, decreased LOC

General Precautions for Administering a Blood Transfusion

- a large vol of refrigerated blood infused rapidly through a CVC = cardiac dysrhythmias - only NS should be added to blood products - meds never added to blood components or piggybacked - decrease risk of septicemia: ensure 1 unit does not exceed prescribed time for administration; blood administration set should be changed for each unit - check bag for date of expiration; components expire at midnight on day marked on bag unless specified - inspect for leaks, abnormal color, clots, and bubbles - blood administered w/in 20-30 minutes from receiving from storage bank - never refrigerate blood products unless in blood bank; if not administered w/in time, return to blood bank - rate of infusion varies with blood component being transfused and depends on client's condition ; generally infused as quick as tolerated - components w/ few RBCs and plts may be infused rapidly, worry about circulatory overload - measure VS and lung sounds before transfusion and again after 15 minutes and q1hr until 1 hr after transfusion completed

Assessing a client for blood transfusion

- assess cultural/religous beliefs on blood transfusions - Jehovah's Witness cannot receive blood - obtain informed consent - explain procedure and determine if client has Hx of blood transfusion and Hx of blood rxns - check VS, renal, circulatory, and respiratory status, and ability to tolerate IV infusions - if temp elevated, notify HCP before beginning transfusion; fever may be a cause for delaying transfusion in addition to masking a possible symptom of acute transfusion rxn

s/s of an immediate transfusion reaction

- chills, diaphoresis - muscle aches, back pain, chest pain - rashes, hives, itching, swelling - rapid thready pulse - dyspnea, cough, wheezing - pallor, cyanosis - apprehension - tingling and numbness - headache - nausea, vomiting, abdominal cramping, diarrhea

Administration of blood transfusion

- maintain standard and transmission-based precautions - insert IV line and infuse NS; maintain infusion at keep-vein-open rate - 18-18g IV needle needed to achieve max flow rate of blood products and prevent damage to RBCs; if smaller gauge used, can RBCs be diluted w/NS - CVC is an acceptable venous access option; for multilumen, use largest catheter port - always check bag for vol - need special tubing; contains a filter designed to trap fibrin clots and other debris that accumulate during blood storage - premedicate w/APAP or diphenhydramine if Hx of previous rxn; PO administered 30 min before transfusion starts, and IV may be given immediately before transfusion starts - instruct client to report abnormalities - determine rate by prescription or agency policy - begin transfusion slowly under supervision; if no rxn noted w/in 1st 15 min, flow can be increased to prescribed rate - during transfusion, monitor for s/s of transfusion rxn; 1st 15 min most critical and nurse should stay w/client - rxn usually evident w/in 1st 50 mL - document client's tolerance and effectiveness by monitoring labs***

Blood warmers

- may be used to prevent hypothermia and adverse rxns when several units of blood administered - special warmers designed for this purpose - DO NOT USE MICROWAVE OVEN OR IN HOT WATER***

CVC: tunneled central venous catheters

- more permanent (Hickman, Broviac, Groshong catheter); long term IV therapy - single or multilumen - inserted in OR and catheter threaded into lower part of vena cava at entrance of right atrium - catheter fitted w/intermittent infusion device to allow access prn and to keep system closed and intact - patency maintained by flushing w/diluted heparin solution or NS, depending on type of catheter

IV Complications: Infection

- occurs from entry of microbes into body thru IV site - venipuncture interrupts the integrity of the skin, 1st line of defense against infection - longer the therapy continues = greater risk for infection - can occur locally at IV site or systematically (sepsis)

IV cannulas: Plastic cannulas

- over-the-needle or in-needle catheter and are used for short-term therapy - over-the-needle preferred for rapid infusion and more comfortable - in-needle can cause catheter embolism if the tip of the cannula breaks

Cryoprecipitates

- prepared from fresh frozen plasma, can be stored for 1 yr. Once thawed, needs to be used; 1 unit administered over 15-30 minutes - replaces clotting factors, esp factor VIII and fibrinogen - effective response measured by monitoring coagulation studies and fibrinogen levels

Filters

- prevents particles from entering the client's veins - Used in IV lines to trap small particles (undissolved substances, meds that have precipitated) - 0.22 mcm filter used for most solutions - 1.2 mcm filter used for lipid/albumin solutions - special filter used for blood components - change filters q24-72hrs to prevent bacterial growth

Blood Transfusion Complication: Transfusion Reactions intervention

- stop the transfusion immediately if suspected - change IV tubing down to IV site and keep IV line open w/NS - Notify HCP and blood bank - Stay w/patient, observe s/s, monitor VS q5min - administer emergency meds as prescribed - obtain a urine specimen/other labs - return blood bag, tubing, attached labels, and transfusion record to blood bank - document occurence, actions taken, and client's response

A client involved in a motor vehicle crash presents to the emergency department 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 ringer's 2. 0.33% sodium chloride (1/3 normal saline) 3. 0.225% sodium chloride (1/4 normal saline) 4. 0.45% sodium chloride (1/2 normal saline)

1 The goal of therapy with this client is to expand intravascular volume as quickly as possible. The 5% dextrose in lactated ringer's (hypotonic solution) would increase intravascular volume and immediately replace lost fluid volume until a transfusion can be administered, resulting in an increase in the client's blood pressure. The solutions in the remaining options would not be given to this client because they are hypotonic solutions and, instead of increasing intravascular space, the solutions would move into the cells via osmosis

The nurse is completing a time tape for a 1000 mL IV bag that is scheduled to infuse over 8 hours. The nurse has just placed the 11AM marking at the 500 mL level. The nurse should place the mark for noon at which numerical level (mL) on the time tape? _____ mL

375 mL If the IV is scheduled to run over 8 hours, then the hourly rate is 125 mL/hr. Using 500 mL as the reference point, the next hourly marking would be at 375 mL, which is 125 mL less than 500.

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 be distended by the tourniquet before the vein was cannulated. Client discomfort varies with the client, the site, and the nurse's insertion technique and is not a reliable measure of cathater placement. The nurse should not advance the catheter until the placement in the vein is verified by blood return.

Peripheral IV sites to avoid

- edematous extremity - arm that is weak, traumatized, or paralyzed - arm on same side as a mastectomy - arm with an arteriovenous fistula or shunt for dialysis - skin area that is infected

IV containers

- containers may be glass or plastic - squeeze plastic bag to ensure intactness and assess glass bottle for cracks before hanging - Do not write on a plastic IV bag with a marking pen bc the ink may be absorbed thru the plastic. Use a label and a ballpoint pen for writing on the label***

Electronic IV infusion devices

- control the amt of fluid infusing and should be used with central venous lines, arterial lines, solutions containing meds, and PN infusions. - syringe pump used when a small vol of med is administered; syringe contains the med and solution fits into a pump and is set to deliver med at a controlled rate - Check electrolye IV infusion devices frequently. Although these devices are electronic, this does not ensure that they are infusing solutions and meds accurately***

delayed transfusion reactions

- an occur days to years after a transfusion - s/s: fever, mild jaundice, decreased Hct lvl

Macrodrip chamber

- used for solution that is thick or to be infused rapidly - drop factor = 10-20 gtt/mL - read tubing package to determine drop factor

IV Complications: Infection at risk clients

- immunocompromised (cancer, HIV, AIDS) - chemotherapy: altered or lowered WBC count - older clients: aging alters the effectiveness of immune system - DM

The nurse is administering 1 unit of packed red blood cells (PRBCs) to a client who has never received a blood transfusion. The client suddenly becomes apprehensive and complains of back pain after the first 10 minutes of administration. What should the nurse do?

Signs of an immediate transfusion reaction include the following: chills, and diaphoresis; muscle aches, back pain, or chest pain; rash, hives, itching, and swelling; rapid, thready pulse; dyspnea, cough, or wheezing; pallor or cyanosis; apprehension; tingling and numbness; headache; and nausea, vomiting, abdominal cramping, and diarrhea. In the event that a transfusion reaction is suspected, the nurse should FIRST STOP THE INFUSION. The nurse should then CHANGE THE IV TUBING DOWN TO THE IV SITE, KEEP THE IV LINE OPEN W/NS, NOTIFY HCP AND BLOOD BANK, and RETURN BLOOD BAG AND TUBING TO THE BLOOD BANK. The nurse should COLLECT A URINE SPECIMEN. The nurse IMPLEMENTS PRESCRIPTIONS and STAYS WITH THE CLIENT and MONITORS THE CLIENT CLOSELY UNTIL STABILIZED.

A client with a peripherally inserted central venous catheter (PICC) in the right upper extremity suddenly exhibits chest pain, dyspnea, hypotension, and tachycardia. The nurse suspects an embolism related to the PICC line. What should the nurse do?

When a client has any type of central catheter, there is a risk for breaking of the catheter, dislodgement of a thrombus, or entry of air into the circulation, all of which can lead to an embolism. Signs and symptoms that this complication is occurring include sudden chest pain, dyspnea, tachypnea, hypoxia, cyanosis, hypotension, and tachycardia. If this occurs, the nurse should CLAMP THE CATHETER, PLACE THE CLIENT ON THE LEFT SIDE WITH THE HEAD LOWER THAN THE FEET (TO TRAP THE EMBOLISM IN THE RIGHT ATRIUM OF THE HEART), ADMINISTER OXYGEN, AND NOTIFY THE HCP.

IV Complications: Circulatory overload s/s

- increased BP, distended jugular veins, rapid breathing, dyspnea, moist cough and crackles

Central Venous Catheters (CVC)

- used to deliver hyperosmolar solutions, measure central venous pressure, infuse parenteral nutrition, or infuse multiple IV solutions or meds - position determined by radiography after insertion - may be single, double, or triple lumen - may be inserted peripherally and threaded thru the basilic or cephalic vein into the superior vena cava, inserted centrally thru the internal jugular or subclavian veins, or surgically tunneled thru subcutaneous tissue - multilumen catheters: more than one med can be administered at the same time w/o incompatibility problems, and only one insertion site is present - for insertion, tubing change, or line removal: place client in Trendelenburg's position if not contraindicated or in supine position and instruct to perform Valsalva maneuver to increase pressure in the central veins when IV system is open ***

IV therapy purpose and uses

- used to sustain clients who are unable to take oral substances - replaces water, electrolytes, and nutrients more rapidly than PO - immediate access to vascular system for rapid delivery of solutions (can be a risk; be sure to check prescriptions and correct solution/med administered; 6 rights for med administration)*** - provides a vascular route for administration of meds and blood

Granulocytes

- used to treat a client with sepsis or neutropenic client with infection unresponsive to antibiotics - effective response assessed by monitoring WBC and differential counts

Intermittent infusion devices

- used when IV accessibility desired for intermittent administration of meds by IV push or IV piggyback - patency is maintained by periodic flushing with NS - Flush 1-2 mL of NS to confirm placement of IV cannula, administer prescribed med and flush again w/1-2 mL of NS

Selection of Peripheral IV site

- veins in hand, forearm, and antecubital fossa are suitable sites - Forearms is most frequently placed sites for inserting IV cannula/needle bc the bones act as a natural support and splint*** - veins in legs and feet are not suitable for adult clients bc of risk for thrombus formation and possible pooling of meds in areas of decreased venous return - Assess veins on both arms closely before selecting a site - start IV infusion distally to provide the option of proceeding up the extremity if the vein is ruptured or infiltration occurs; if infiltration occurs from antecubital vein, lower veins in same arm cannot be used for further puncture sites - determent client's dominant side and select opposite side for venipuncture - Bending elbow on arm with IV may easily obstruct the flow of solution, causing infiltration that could lead to thrombophlebitis - Avoid checking BP on arm receiving IV infusion - Do not place restraints over venipuncture site - Use armboard PRN when venipuncture site is located in an area of flexion

s/s of transfusion reaction in an unconcious patient

- weak pulse, fever, tachycardia or bradycardia, hypotension, visible hemoglobinuria, oliguria or anuria

IV cannulas: Butterfly sets

- wing-tip needle w/metal cannula, plastic/rubber wings, and plastic catheter or hub - needle = 0.5-1.5 in w/ gauge sizes from 16-26 - infiltration is more common - commonly used in children and older clients, whose veins are likely to be small and fragile

The nurse has a prescription to hang at 1000 mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride and needs to add the medication to the IV bag. The nurse should plan to take which action immediately after injecting the potassium chloride into the port of the IV bag? 1. Rotate the bag gently 2. Attach the tubing to the client 3. Prime the tubing with the IV solution 4. Check the solution for yellowish discoloration

1 After adding a medication to a bag of IV solution, the nurse should agitate or rotate the bag gently to mix the medication evenly in the solution. The nurse should then attach a completed medication label. The nurse can then prime the tubing. The IV solution should have been checked for discoloration before the medication was added to the solution. The tubing is attached to the client last.

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client's intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which complication has occured? 1. Infection 2. Phlebitis 3. Infiltration 4. Thrombosis

3 An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling are the results of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and start a new IV line at another site. Infection, phlebitis, and thrombophlebitis are likely to be accompanied by warmth at the site, not coolness.

A client has just undergone insertion of a central venous catheter at the bedside. The nurse would be sure to check which results before initiating the flow rate of the client's intravenous (IV) solution at 100 mL/hr? 1. serum osmolality 2. serum electrolyte levels 3. portable chest xray film 4. intake and output recors

3 Before beginning administration of IV solution, the nurse should assess whether the chest radiograph reveals that the central catheter is in the proper place. This is necessary to prevent infusion of IV fluid into pulmonary or subcutaneous tissues. The other options represent items that are useful for the nurse to be aware of in the general care of this client, but they do not relate to this procedure.

IV Complications: Catheter embolism

An obstruction that results from breakage of catheter tip during IV insertion or removal

IV Complications: Extravasation

form of tissue damage caused by seepage of vesicant or irritant solutions into the tissues - requires immediate HCP notification so treatment can be prescribed to prevent tissue necrosis

IV Complications: Thrombophelbitis

hard and cordlike vein, heat, redness, tenderness at site, IV infusion sluggish

IV Complications: Phlebitis s/s

heat, redness, tenderness at site, IV infusion sluggish - NOT swollen or hard

IV Complications: Electrolyte Overload prevention and intervention

- Assess labs - Verify correct solution - Calculate and monitor flow rate - Use electronic IV infusion device and frequently assess rate - Add a time tape/label to IV bag - Place a red medication sticker on bag if medication, such as KCl, has been added - Monitor for s/s and notify HCP - Lactated Ringer's solution contains K and should not be administered to clients with acute kidney injury or chronic kidney disease ***

IV Complications: Hematoma prevention and intervention

- Avoid piercing the posterior wall of the vein during insertion - Do not apply a tourniquet to extremity immediately after an unsuccessful venipuncture - When DCing an IV, apply pressure for 2-3 minutes and elevate extremity; apply for longer if have blood disorder or on anticoagulants - if hematoma develops, elevate extremity and apply pressure and ice as prescribed

CVC: PICC line

- used for long-term IV therapy, frequently used in the home - basilic vein usually used, but median cubital and cephalic veins in antecubital area can be used - catheter is threaded so catheter tip may terminate in the subclavian vein or superior vena cava - small amt of bleeding may occur at time of insertion and may continue for 24 hrs but bleeding thereafter is not expected - phelebitis is a common complication - insertion is below the heart level; therefore air embolism is not common

Platelet transfusion

- used to Tx thrombocytopenia and platelet dysfunction - crossmatching not required but usually done (contain few RBCs) - volume may vary, always check bag for volume - plts administered immediately upon receipt from blood bank and given RAPIDLY for 15-30 minutes - effective response based on increased plt; plt count evaluated 1 hr and 18 to 24 hrs after transfusion - 1 unit = 5,000 - 10,000 cells/mm3 increase expected

The nurse notes that the site of a client's peripheral intravenous (IV) 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. Coolness at the site would be noted if the IV catheter was infiltrated. An allergic reaction produces a rash, redness, and itching. A mahor reaction, such as hypersensitivity, can cause dyspnea, a swollen tongue, and cyanosis.

A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which action(s) in the care of this client? Select all that apply. 1. Notify the health care provider 2. Remove the IV catheter at the 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 Phlebitis is an inflammation of the vein that can occur from mechanical or chemical (medication) trauma or from a local infection and can cause the development of a clot (thrombophlebitis). 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 has occurred, the nurse also notifies the HCP about 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.

Actions for removing a peripheral IV line

1. Check prescription and explain procedure; ask client to hold extremity still during removal 2. Turn off IV tubing clamp and remove dressing and tape covering the site, while stabilizing the catheter 3. Apply light pressure w/sterile gauze and withdraw catheter using slow, steady movement, keeping the hub parallel to the skin 4. Apply pressure for 2-3 minutes, using dry sterile gauze (apply for longer is client has bleeding disorder or taking anticoagulants) 5. Inspect site for redness, drainage, swelling; check catheter for intactness 6. Document procedure and client's response

Actions for Inserting a Peripheral IV line

1. Check prescription to determine type & size of infusion device; prep IV tubing & solution; prime IV tubing; explain procedure to the client 2. Select vein for insertion; apply tourniquet and palpate the vein for resilience 3. Clean the skin with an antimicrobial solution, using an inner to outer circular motion 4. Stabilize the vein below insertion site and puncture skin and vein, observe for blood flashback, then advance catheter into the vein (if unsuccessful, use a new sterile device to reattempt) 5. Apply pressure above the insertion site w/the middle finger of nondominant hand and retract the stylet from the catheter; connect the end of the IV tubing to the catheter tubing, secure it, and begin IV flow 6. Tape and secure insertion site with a dressing as specified by agency procedure; label tubing, dressing, and solution w/date and time 7. Document specifics about procedure such as number of attempts, insertion site, type and size of device, solution, rate, time, and client's response

The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instructions if the client made which statement? 1. "I need to wear a Medic-Alert tag or bracelet." 2. "I need to restrict my activity while this catheter is in place." 3. "I need to have a repair kit available in the home for use if needed." 4."I need to keep the insertion site protected when in the shower or bath."

2 The client should be taught that only minor activity restrictions apply with this type of catheter. The client should protect the site during bathing and should carry or wear a Medic-Alert identification. The client should have a repair kit in the home for use as needed because the catheter is for long-term use.

The nurse is preparing a continous intravenous (IV) 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. There is no need to obtain a new IV bag because the bag was not contaminated. Wiping with Betadine or alcohol is insufficient and is contraindicated because the spike will be inserted into the IV bag.

A health care provider has written a prescription to discontinue an intravenous (IV) 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 2x2 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. A Betadine swab would irritate the opened puncture site and would not stop the blood flow. An adhesive bandage or elastic wrap may be used to cover the site once hemostasis has occurred.

A client with the recent diagnosis of myocardial infarction and impaired renal function is recuperating on the step-down cardiac unit. The client's blood pressure has been borderline low and intravenous (IV) fluids have been infusing at 100 mL/hr via a central line catheter in the right internal jugular for approximately 24 hrs to increase renal ouput and maintain the blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and is coughing. The nurse determine that the client is most likely experiencing which complication of IV therapy? 1. Hematoma 2. Air embolism 3. Systemic infection 4. Circulatory overload

4 Circulatory (fluid) overload is a complication of intravenous therapy. Signs include rapid breathing, dyspnea, a moist cough, and crackles. When circulatory overload is present, the client's blood pressure also increases. Hematoma is characterized by ecchymosis, swelling, and leakage at the IV insertion site, as well as hard and painful lumps at the site. Air embolism is characterized by tachycardia, dyspnea, hypotension, cyanosis, and decreased level of conciousness. Systemic infection is characterized by chills, fever, malaise, headache, nausea, vomiting, backache, and tachycardia.

Epidural catheters

- catheter placed in the epidural space for the administration of analgesics; reduces the amt of med needed to control pain; fewer SE - assess VS, LOC, and motor and sensory function - monitor for s/s of infection and be sure that the catheter is secures to the skin and that all connections are taped to prevent disconnection - check prescription regarding solutions/meds - for continous infusion. monitor electronic infusion for rate - aspiration is done before injecting meds; if more than 1 mL of clear fluid or blood returns, med is not injected and HCP or anesthesiologist is notified immediately (catheter may have migrated into subarachnoid space or blood vessel)

Client ID and compatibility for blood transfusion

- check prescription for administration of blood product - most critical phase = confirming product compatibility and verifying client ID - 2 licensed nurses need to check prescription, client ID, and client ID band, verifying name and number identical to blood tag - ask client to state name and compare name to ID band - check blood bag tab, label, and blood requisition form for ABO and Rh compatibility - if note any inconsistencies, notify blood bank immediately

Microdrip chamber

- delivers ~60 gtt/mL (read package for drop factor) - used if fluid will be infused at a slow rate (<50 mL/hr) or if solution contains potent meds that need to be titrated (critical care setting, peds clients)

Washed red blood cells

- depletion of plasma, platelets, and leukocytes) may be prescribed for clients w/ Hx of allergic transfusions or those who underwent hematopoietic stem cell transplant***

Crossmatching

- determines compatibility; donor's RBCs combined with recipient's serum and Coombs' serum - compatible = no RBC agglutination occurs - must be tested for compatibility, if not compatible = life threatening rxn can occur

IV gauges

- diameter of the lumen of the needle/cannula - smaller gauge number = larger diameter of lumen; allow higher fluid rate and administration of higher concentrations of solutions - larger gauge number = smaller diameter of lumen - size of gauge depends on solution administered and diameter of vein - for rapid emergency fluid/blood/anesthetic administration, large-diameter lumen needles/catheters are used (14g, 16g, 18g, 19g) - for peripheral fat emulsion (lipids) use 20g or 21g - For standard IV fluid and clear liquid IV meds, use 22g or 24g - If client has very small veins, use 24g or 25g

Autologous blood donation

- donation of client's own bloob before a scheduled procedure = autologous donation; reduces risk of disease transmission and potential transfusion complications - not an option if client has leukemia or bacteremia - donation can be made every 3 days as long as Hgb remains within a safe range - donations should begin within 5 weeks of transfusion date and end 3 days before date of transfusion

Blood Transfusion Complication: Transfusion Reactions

- happens as a result of receiving a blood transfusion - Types: hemolytic, allergic, febrile or bacterial reactions (septicemia), or transfusion-associated graft-versus-host disease (GVHD)

Reactions to Blood Transfusions

- if rxn occurs, stop transfusion, change IV tubing down to IV site, keep IV line open w/NS, notify HCP and blood bank, return blood bag and tubing to blood bank - do not leave client alone, monitor client for life-threatening symptoms - obtain appropriate lab samples (blood and urine samples; free Hgb indicates that RBCs were hemolyzed

IV Complications: Phlebitis and Thrombophelbitis

- inflammation of the vein that can occur from mechanical or chemical (meds) trauma or from local infection - can cause the development of a clot (thrombophelbitis)

IV Complications: Infection s/s

- local: redness, swelling, drainage at site - systemic: chills, fever, malaise, HA, NV, backache, tachycardia

IV Complications: Phlebitis and Thrombophelbitis preventions and intervention

- use a IV cannula smaller than the vein, avoid using very small veins when administering irritating solutions - avoid using lower extremities for IV - avoid venipuncture over an area of flexion - anchor cannula and loop of tubing w/tape - use armboard or splint prn if client restless or active - change venipuncture site q72-96hrs (3-4 days) - if phlebitis occurs, remove the IV immediately, restart in opposite extremity, notify HCP if phelbitis suspected, apply warm moist compresses - if thrombophelbitis occurs, do not irrigate IV catheter, remove IV, notify HCP, restart IV in opposite extremity

IV Complications: Infection prevention and intervention

- assess for risk/predisposition - maintain strict asepsis during IV care - monitor for s/s - monitor WBC - check fluid containers for cracks, leaks, cloudiness, other evidence of contamination - change IV tubing no more frequently than q96h; change dressing when soiled or contaminated - label IV site, bag, tubing w/date and time to ensure they are changed on time - ensure IV solution is not hanging for more than 24hrs - in infection occurs, notify HCP, DC IV, place venipuncture device in sterile container for possible culture - prep blood cultures as prescribed - restart IV in opposite arm to differentiate sepsis from local infection - DM clients usually does not receive dextrose (glucose) solutions bc can increase the blood glucose lvl***

IV Complications: Infiltration prevention and intervention

- avoid venipuncture over an area of flexion - anchor the cannula and a loop of tubing securely w/tape - use an armboard or splint prn if client restless/active - monitor IV rate for decrease or cessation of flow - evaluate IV site for infiltration by occluding the vein proximal to the IV site. if fluid continues to flow, cannula is probably outside of the vein (infiltrated); if IV flow stops after occlusion, IV still in vein - lower IV container below IV site and monitor for appearance of blood in tubing; if blood appears, IV in vein - if infiltration has occurred, remove IV immediately; elevate extremity and apply compresses (warm or cool, depending on the IV solution that was infusing and HCP's prescription) - Do not rub an infiltrated area, can cause hematoma

Initiation & administration of IV solutions

- Check IV solution to prescription for type, amt, % of solution, and rate of flow; 6 rights for med administration - Assess health status and medical disorders; ID conditions that contraindicate use of a particular solution/IV equipment (allergy) - Check client ID and explain procedure to the client; assess previous experience and preference for IV site - Wash hands and wear gloves - sterile techinque when inserting or changing dressing of IV - Change venipuncture site q72-96hrs (3-4 days) - Change IV dressing when dressing is wet, contaminated or specified - Change IV tubing q96hrs (4 days) or w/change of venipuncture site - Do not let an IV bag/bottle hang for more than 24 hrs to diminish the potential for bacterial contamination and sepsis - Do not allow the IV tubing to touch the floor to prevent potential bacterial contamination - Before adding medications to solutions, swab access ports w/70% alcohol

IV Complications: Circulatory overload prevention and intervention

- ID clients at risk for circulatory overload (respiratory, cardiac, renal, or liver disease, older clients, very young)*** - Calculate and monitor the drip (flow) rate frequently - Use an electronic IV infusion device and frequently check the drip rate/setting atleast q1h for adults - Add a time tape (label) to the IV bag/bottle next to the volume markings. Mark on the tape the expected hrly decrease in vol based on rate - Monitor for s/s; if occurs, decrease rate to minimum, at a keep-vein-open rate; elevate HOB; keep client warm; assess lung sounds; assess for edema; notify HCP

IV Complications: Tissue Damage prevention and intervention

- Use a careful and gentle approach when applying the tourniquet - avoid tapping the skin over the vein when starting an IV - monitor for ecchymosis when penetrating the skin with the cannula - assess for allergies to tape or dressing adhesives - monitor skin color changes, sloughing of skin, or discomfort at IV site - Notify HCP if tissue damage suspected - always document a complication, assessment findings, actions taken, and client's response

Patient-controlled analgesia (PCA)

- allows client to self-adminsiter IV meds (analgesics); the client can administer bolus doses at set intervals and the pump can be set to lock out bolus doses that are not within the preset time frame to prevent OD - regimen may include a basal rate along with demand dosing

Blood salvage: blood donation

- an autologous donation that involves suctioning blood from body cavities, joint spaces, or other closed body sites - blood may need to be "washed": special process to remove tissue debris before reinfusion

IV Complications: Infiltration

- seepage of the IV fluid oit of the vein and into the surrounding interstitial spaces - occurs when an access device as become dislodged or perforates the wall or vein or when venous backressure occurs because of a clot or venospasm

IV Complications: Tissue Damage

- skin, veins, and subcutaneous tissue most commonly damaged - can be uncomfortable and cause permanent negative effects

IV tubing

- special tubing used for meds that absorb into plastic (check specific med administration) - Extension tubing can be added to an IV tubing set to provide extra length to the tubing. Add extension tubing to the IV tubing set for children, clients who are restless, or clients who have special mobility needs***

IV Complications: Air embolism prevention and intervention

- prime tubing before use and monitor for air bubbles - secure all connections - replace IV fluid before bag or bottle is empty - monitor for s/s; if suspected clamp tubing, turn client to left side with HOB lowered (Trendelenberg) to trap air in right atrium, notify HCP

Fresh frozen plasma (FFP)

- provides clotting factors or volume expansion; contains no plts - infused w/in 2 hrs of thawing, while clotting factors still viable; infused over 15-30 minutes - Crossmatching required - effective response based on monitoring prothrombin time and partial thromboplastin time, and resolution of hypovolemia

Needleless infusion devices

- recessed needles, plastic cannulas, and one-way valves; decrease exposure to contaminated needles - do not administer PN or blood products thru a one-way valve

IV Complications: Catheter embolism prevention and intervention

- remove catheter carefully - inspect catheter when removed - if tip broken, place tourniquet as proximally as possible to IV site on affected limb, notify HCP immediately, prep for radiograph, and prep for surgey to remove catheter pieces if necessary

Precautions for IV lines

- route of entry of microbes = infection risk - fluid (circulatory) overload or electrolyte imbalances DT excessive or too rapid infusion of IV fluids - incompatibilities btwn solution and med - clients w/HF usually not given solution containing saline bc this type of fluid promotes retention of water and would exacerbate HF bi increasing fluid overload***

Isotonic solutions

- same osmolality as body fluids - increases EC fluid volume - Does not enter the cell because no osmotic force exists to shift the fluids

Blood Transfusion Complication: Citrate toxicity

- citrate: anticoagulant used in blood products; metabolized in liver - rapid administration of multiple units of stored blood may cause hypocalcemia and hypomagnesemia when citrate bonds to Ca and Mg; This results in citrate toxicity causing myocardial depression and coagulopathy - clients most at risk: liver dysfunction, neonates w/immature liver function - treatment = slowing or stopping transfusion to allow citrate to be metabolized; hypocalcemia and hypomagnesemia also treated w/replacement therapy

A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which action(s) to reduce the risk of possible transfusion complications? Select all that apply. 1. Ask a family member to donate blood ahead of time 2. Give an autologous blood donation before the surgery 3. Take iron supplements before surgery to boost hemoglobin levels 4. Request that any donated blood be screened twice by the blood bank 5. Take adequate amounts of vitamin C several days prior to the surgery date.

1, 2 A donation of the client's own blood before a scheduled procedure is analogous. Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion complications. The next most effective way is to ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are helpful for iron deficiency anemia but are not helpful in replacing blood lost during the surgery. Vitamin C enhances iron absorption, but also is not helpful in replacing blood lost during surgery.

A client is brought to the emergency department having experienced blood loss related to an arterial laceraton. Fresh-frozen plasma is prescribed and transfused to replace fluid and blood loss. The nurse understands that which is the rationale for transfusing fresh-frozen plasma to this client? 1. To treat the loss of platelets 2. To promote rapid volume expansion 3, Because a transfusion must be done slowly 4. Because it will increase the hemoglobin and hematocrit levels

2 Fresh-frozen plasma is often used for volume expansion as a result of fluid and blood loss. It does not contain platelets, so it is not used to treat any type of low platelet count disorder. It is rich in clotting factors and can be thawed quickly and transfused quickly. It will not specifically increase the hemoglobin and hematocrit level.

A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hand with the blood product at the client's bedside? 1. Lactated RInger's 2. 0.9% sodium chloride 3. 5% dextrose in 0.9% sodium chloride 4. 5% dextrose in 0.45% sodium chloride

2 Sodium chloride 0.9% (NS) is a standard isotonic solution used to precede and follow infusion of blood products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells. Lactated Ringer's is not the solution of choice with this procedure.

The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring? 1. 5 minutes 2. 15 minutes 3. 30 minutes 4. 45 minutes

2 The nurse must remain with the client for the first 15 minutes of a transfusion, which is usually when a transfusion reaction may occur. This enables the nurse to detect a reaction and intervene quickly. The nurse engages in safe nursing practice by obtaining coverage for the other assigned clients during this time. Therefore, the remaining options are incorrect time frames.

The nurse has just received a unit of packed red blood cells from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with which item? 1. An air vent 2. Tinted tubing 3. An in-line filter 4. A microdrip chamber

3 The tubing used for blood administration has an in-line filter. The filter helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused into the client. Tinted tubing is incorrect because blood does not need to be protected from light. The tubing should be macrodrip, not microdrip, to allow blood to flow freely through the drip chamber. An air vent is unnecessary because the blood bag is not made of glass.

The nurse listening to the morning report, learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which daily serum laboratory studies to assess the effectiveness of the transfusion? 1. Hematocrit level 2. Erythrocyte count 3. Hemoglobin level 4. White blood cell count

4 The client who has neutropenia may receive a transfusion of granulocytes, or white blood cells. These clients often have severe infections and are unresponsive to antibiotic therapy, The nurse also continues to monitor the client for signs and symptoms of infection. Erythrocyte count and hemoglobin and hematocrit levels are determined after infusion of packed red blood cells.

Blood Transfusion Complication: Iron overload

a delayed transfusion complication that occurs in clients who receive multiple blood transfusions (anemia, thrombocytopenia)

CVC: vascular access ports (implantable port)

- surgically implanted under the skin (Port-a-Cath, Mediport, Infusaport); long-term adminstration of repeated IV therapy - for access, the port requires palpation and injection thru the skin into the self-sealing port with a noncoring needle (Huber-point needle) - patency maintained by periodic flushing w/ diluted heparin as prescribed

Complications of a Blood Transfusion

- transfusion rxns - circulatory overload - septicemia - iron overload - disease transmission - hypocalcemia - hyperkalemia - citrate toxicity

A client had a 1000 mL bag of 5% dextrose in 0.9% sodium chloride hung at 3PM. The nurse making rounds at 3:45 PM finds that the client is complaining of a pounding headache and is dyspneic, is experiencing chills, and is apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first? 1. Slow the IV infusion 2. Sit the client up in the bed 3. Remove the IV catheter 4. Call the health care provider

1 The client's symptoms are compatible with circulatory overload. This may be verified by noting that 600 mL has infused in the course of 45 minutes. The first action of the nurse is to slow the infusion. Other actions may follow in rapid sequence. The nurse must elevate the head of the bed to aid the client's breathing, if necessary. The nurse also notifies the HCP. The IV catheter is not removed, it may be needed for the administration of medications to resolve the complication