Nursing Care For IV Therapy Ch. 7
The nurse has placed a tourniquet on the patient's left arm to help dilate the vein before insertion of the catheter. What is the maximum time that the nurse can leave the tourniquet in place?
3 minutes
A group of nursing students have learned to be vigilant when preparing and administering medications to clients. Medication administration through the IV route is often considered to be more dangerous than administration by other routes because:
Drugs given in this manner cannot be retrieved once they have been delivered so this route of drug administration is considered the most dangerous.
The medication prescription states to administer acetaminophen (Tylenol), 650 mg orally for a temperature of more than 38° C. The medication bottle states Tylenol (acetaminophen), 325 mg tablets. The nurse takes the client's temperature and notes that it is 101° F. The nurse plans to take which action?
Administer two Tylenol tablets To convert Fahrenheit to Celsius, subtract 32, and divide the result by 1.8:
A nurse is administering a prescribed medication to a client through the intravenous (IV) route. In which of the following cases is the IV route of administration most widely used?
An IV administration is given either continuously or intermittently when clients have disorders such as serious burns that affect the absorption or metabolism of medications. An IV route is widely used when a quick response, not a gradual response, is needed during an emergency. It is also used to avoid the discomfort of repeated intramuscular injections, not intradermal injections, to a client. An IV route is not used widely for single doses of insulin, though an IV route is used for insulin infusion.
A nurse is careful when giving an antineoplastic medication to a client through a tunneled catheter. The nurse knows that antineoplastic medications can cause which of the following long-term adverse effects to care providers?
Antineoplastic agents are toxic to both normal and abnormal cells. Long-term exposure can lead to changes in fast-growing body cells, including reduction in sperm count, changes in ova, or defects in the fetal tissue. When transferred to the caregiver through skin contact, inhalation of tiny fluid droplets or dust particles on which the droplets fall, or oral absorption of medication residue during hand-to-mouth contact, these medications can immediately cause headaches, nausea, dizziness, and burning or itching of the skin.
A client's intermittent IV administration of a dose of an antibiotic has just been completed. The client is not receiving IV fluids so the nurse is aware of the need to flush the CVC. What solution should the nurse use to flush the client's CVC?
Heparin 100 units per mL is the usual strength used for flushing a CVC.
The nurse is assisting with flushing a central venous line. Which solution should the nurse prepare for this flush?
Heparin is recommended for flushing central venous lines.
The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which has probably occurred?
Infiltration
The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item?
Sterile 2 × 2 gauze
The nurse is completing the insertion of an IV catheter in a patient's right hand. What is the last step that the nurse should perform at this time?
The date, time, IV site, type of cannula, and signature of person inserting should all be documented.
Morphine sulfate, 2.5 mg, is prescribed for a child. The safe pediatric dose is 0.05 to 0.1 mg/kg/dose. The child weighs 50 kg. Which statement describes the prescribed dosage for this child?
The dose is within the safe dosage range. 0.05 mg/kg/dose × 50 kg = 2.5 mg/dose 0.1 mg/kg/dose × 50 kg = 5 mg/dose
A hospital client with a triple-lumen CVC is exhibiting signs and symptoms of a pulmonary embolism. The care team has performed an emergency assessment and ordered STAT IV infusions of heparin and morphine sulfate. The nurse is aware that the two drugs are incompatible. What action should the nurse take?
With multiple lumens, incompatible substances or more than one solution or drug can be given simultaneously through a CVC. Each infuses through a separate channel and exits the catheter at a different location near the heart. Consequently, the nurse may safely administer the two medications simultaneously.
The medication prescribed is atropine sulfate, 0.4 mg intramuscularly, immediately. The medication label states atropine sulfate, 0.3 mg/0.5 mL. The nurse prepares how much medication to administer the dose?
0.4 mg * 0.5 mL / 0.3 mg= 0.66 or 0.7 mL
The medication prescribed is heparin sodium 650 units subcutaneously, every 12 hours. The medication vial reads heparin sodium 1000 units/mL. The nurse prepares how many milliliters to administer one dose?
0.65 mL
The medication prescribed is meperidine hydrochloride (Demerol), 35 mg intramuscularly. The medication label states meperidine hydrochloride (Demerol), 50 mg/mL. The nurse plans to prepare how much medication to administer the dose?
0.7 mL
The medication prescribed is hydromorphone hydrochloride (Dilaudid), 3 mg intramuscularly, every 4 hours as needed. The medication label reads hydromorphone hydrochloride (Dilaudid), 4 mg/1 mL. The nurse should prepare to administer how many mL to the client?
0.75 mL
The physician prescribes a patient to receive 1000 mL of Dextrose 5% and water to be infused over 10 hours. The drip factor is 15 gtt per mL. The infusion set should be regulated for how many drops per minute? (Round to the nearest whole number.)
1000 mL/600 min × 15/1 = 24.9 or 25 gtt/min
A health care provider's prescription reads as follows: "Ampicillin, 125 mg intramuscular every 6 hours." The medication label reads, "1 gram when reconstituted with 7.4 mL of bacteriostatic water." How many milliliters should the nurse draw up for one dose?
125 mg ------- × 7.4 mL = 0.925 mL/dose 1000 mg
The medication prescribed is metoclopramide hydrochloride (Reglan) 10 mg intramuscularly times one dose. The medication label reads metoclopramide hydrochloride (Reglan), 5 mg/mL. The nurse prepares how much medication to administer the dose?
2 mL
The medication prescribed is digoxin (Lanoxin), 0.25 mg orally, daily. The medication label reads digoxin (Lanoxin), 0.125 mg/tablet. The nurse should prepare how many tablet(s) to administer the dose?
2 tablets
A patient is prescribed to receive 500 mL of Dextrose 5% and 0.9% normal saline to infuse over 24 hours. The infusion set delivers 60 drops per mL. At what rate should the nurse regulate the infusion set to administer fluid to the patient? (Round to the nearest whole number.)
500 mL/1440 x 60= 20.8 or 21 gtt/min.
A patient is to receive normal saline, 500 mL over 8 hours. The pump should be set to infuse how many mL of the fluid per hour? (Round to the nearest whole number.)
63 mL/hr
A patient is prescribed a medication that is to be delivered the quickest possible way. Which type of infusion should the nurse prepare for the patient?
A bolus injection, sometimes called an intravenous (IV) push
A nurse is administering a prescribed dose of a medication to a client through a percutaneous CVC. In which of the following cases is a percutaneous CVC used?
A percutaneous CVC is used when clients require short-term fluid or medication therapy lasting a few days or weeks.
The nurse is providing care for a patient with leukemia who is beginning chemotherapy. Treatment is expected to occur over 1 week each month and may last months to years, depending on the patient's response. Which type of IV line will best meet the patient's needs?
A tunneled catheter is used when IV therapy is expected to last for months to years, because it provides long-term venous access.
A nurse is caring for a client on IV therapy. The IV tubing has a volume-control set. Which of the following is a function of the volume-control set?
A volume-control set is used to administer a small volume of IV medication at intermittent intervals to avoid accidentally overloading the circulatory system.
The nurse is caring for an 87-year-old patient recovering from abdominal surgery. The patient has a continuous IV infusion to supply nutrients and antibiotics. For which assessment finding should the nurse provide immediate intervention?
Phlebitis, an inflammation of a vein, has signs and symptoms of redness, warmth, swelling, and pain at the infusion site. Phlebitis is a complication of IV therapy, and the registered nurse (RN) should be alerted and the IV most likely removed. IV sites are dated when the catheter is inserted. Loose tape should be secured, but is not a higher priority than redness at the IV site. IV pumps have a battery and can be unplugged temporarily.
Prior to the administration of an IV medication, a nurse has attempted to flush a client's saline lock which has been disconnected for several hours. The nurse encounters resistance when instilling the saline solution and the client states that this causes pain in the region of the saline lock. What should the nurse do next?
If the nurse is unable to flush a saline lock, and if attempts to flush are met with pain, it is necessary to discontinue the saline lock and establish new IV access.
A nurse needs to administer an IV medication to an elderly client who has fragile veins. Which of the following interventions should the nurse explore when a client has fragile veins?
Insertion of a percutaneous central venous line is often better than risking the trauma of repeated attempts at restarting or changing peripheral IV sites
A client is being treated in the hospital for an infection and is receiving 1000 mg of the antibiotic vancomycin every 12 hours, with each dose to be administered over 60 minutes. This client is receiving what type of IV medication administration?
Intermittent infusion is short-term (from minutes up to 1 hour) parenteral administration of medication.
The nurse suspects that a patient's IV catheter has developed a clot. Which factors should the nurse consider when determining how the clot formed within the catheter?
Irritation, increased venous pressure, backup of blood into the line, or bending of the extremity all can slow the infusion rate, which increases risk of clot formation.
The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which?
Phlebitis
A nurse is using a multiple lumen CVC to administer a dose of prescribed combined medication to a client. The nurse first pierces the port with a syringe containing saline solution and instills the solution. Which of the following describes the reason for the nurse's action?
Piercing the port with a syringe containing the saline solution and instilling the flush solution clears the catheter of the previous solution.
A patient is prescribed to receive a medication as a bolus. Which medication should the nurse question for administration as a bolus?
Potassium is never given as an IV bolus because of the potential for life-threatening cardiac dysrhythmias.
The nurse is assisting with the monitoring of a patient receiving IV therapy. Approximately 20 minutes after an intermittent infusion scheduled to run over 1 hour is started, the nurse notices that the bag is half empty. Which assessment findings may have contributed to this?
The drip rate is set too fast The solution is placed too high above the patient
After puncturing the skin when inserting an IV catheter, the nurse obtains a blood return; however, the blood return stops after the stylet is removed. What should the nurse do at this time?
The nurse needs to remove the catheter and begin again.
The nurse notes that a patient's IV infusion of 1 liter 0.45% normal saline expected to infuse over 8 hours has infused in under 2 hours. What action(s) should the nurse take at this time?
The nurse should assess the patient's orienatation, notify the RN, measure blood pressure and heart rate, and complete a neurologic assessment.
A nurse needs to administer medications to a client through an IV port. Which of the following actions should the nurse perform to ascertain that the IV catheter is in the vein?
The nurse should observe for blood in the tubing near the IV catheter or insertion device because blood validates that the IV catheter is in the vein.
A nurse is using a volume-control set to administer a prescribed dose of medication to a client who is on fluid therapy. Which of the following actions should the nurse perform to mix the medication thoroughly in the fluid?
The nurse should rotate the fluid chamber back and forth to mix the medication thoroughly in the fluid.
The nurse assesses puffy eyelids, edema, distended neck veins, and shortness of breath in a patient receiving IV therapy. What actions should the nurse take at this time?
The patient is demonstrating signs of fluid overload. The nurse should decrease the IV drip rate, place the patient in high Fowler position, keep the patient warm, monitor vital signs frequently, and administer oxygen if necessary.
When assessing a patient's IV catheter site, the nurse notes that the skin is cool at the site. The skin is tight; edema is present around the catheter; and the patient states the site has been burning for a few hours. What action(s) should the nurse take at this time?
The patient is demonstrating signs of infiltration or extravasation. The nurse should stop the infusion, discontinue the cannula, slightly elevate the extremity, and notify the RN. Cool compresses are used for infiltrated IV fluids.
After receiving morning report, the nurse finds that the IV tubing of a patient has become disconnected from the fluid. The patient is demonstrating confusion, shortness of breath, and a cough. What should the nurse do at this time?
The patient is demonstrating signs of venous air embolism. The nurse should call for help, place the patient in the Trendelenburg position on the left side, monitor vital signs, and notify the RN.
A patient receiving IV antibiotics complains that the cathteter site is painful. The nurse notes that the site appears red, and there is evidence of a palpable cord. Which action should the nurse take first?
The patient shows signs of phlebitis, and the catheter should be removed first.
A nurse needs to administer prescribed antineoplastic medications to a cancer client. Which of the following interventions should the nurse perform to avoid self-contamination? Select all that apply.
To avoid self-contamination, the nurse should cover the medication preparation area with a disposable paper pad, wear a respiratory mask and goggles, and also wear one or two pairs of surgical latex gloves. The nurse should cover the cuffs of the gown with the cuffs of the gloves and pour 70% alcohol over any medication spill to inactivate it.
A nurse is administering a prescribed dose of medication to a client through a medication lock. How often should the nurse flush the medication lock to maintain patency?
To maintain patency, nurses usually flush medication locks every 8 to 12 hours with saline.
