Nursing Skills 2 Exam 1

Which nursing intervention is appropriate when a patient who is undergoing intravenous therapy develops redness, inflammation, swelling, and purulent drainage at the catheter site? Select all that apply.

Cleaning the skin with alcohol Inserting a new intravenous line in another extremity

Which of the following would be consistent with infiltration? (Select all that apply.)

Cool to touch. Swelling around insertion site. Pain with increasing infiltration. Symptoms of infiltration include pallor, coolness to touch, edema, and pain at the insertion site.

Which nursing action can promote the patients safety when continuing IV therapy?

Coordinating the tubing changes with container changes

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.)

Crackles in lungs. Peripheral edema. 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.

Calculate the following problem. Remember to round off the answer to the nearest whole number, because fractions of a drop are to be avoided when calculating IV drip rates.Order: 1000 mL of D51/2NS (dextrose 5% in 0.45% sodium chloride) in 8 hoursAvailable: 1 liter of D51/2NS (dextrose 5% in 0.45% sodium chloride); IV macrodrip tubing 10 gtt per milliliterThe patient should receive ___________ gtt per minute.

21 1000 mL / 8 hours = 125 mL per hour125 mL / 1× 10 gtt/mL / 60 minutes = 20.8 gtt/min = 21 gtt per minute

The nurse hangs 1000 mL of 0.9% normal saline at 0900. The ordered rate is 80 mL/hr and is infusing with microdrip tubing and an EID. The nurse would expect to hang a new IV bag at approximately at what time? ___________(in military time—remember 2400 is midnight)

2130 1000mL ÷ 80 mL/hr = 12.5 hours0900 + 12½ hours = 2130

Calculate the following problem. Remember to round off the answer to the nearest whole number, because fractions of a drop are to be avoided when calculating IV drip rates.Order: 0.9% normal saline at 80 mL per hourIt will take ___________ hours for 2000 mL to infuse.

25 2000 mL / 80 mL/hr = 25 hours

Solve the problem.Order: Lorazepam (Ativan) 6 mg, IV, q6h, as neededMedication available: Lorazepam (Ativan) 4 mg per mLDrug reference: IV maximum infusion rate 2 mg per minuteAt what rate should this medication be administered? IV over ___________ minutes.

3

Order: Oxacillin (Bactocil) 400 mg, IV, q6h.Medication available: 400 mg oxacillin (Bactocil) in 100 mL of D5W.Instruction: Infuse over 40 minutes. Micro-drip tubing (60 gtts/mL) is being used.The infusion pump should be set to ___________ mL per hour.

150

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?

"I am inspecting the catheter for intactness." 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.

The nursing staff attended an in-service on IV fluid management with discussion on patient safety. Which of the following statements, if made by one of the staff, indicates further instruction is needed?

"It is unnecessary to monitor infusion rates when an electronic infusion device is being used." Infusion controllers or electronic infusion devices are imperfect and do not replace frequent, accurate nursing evaluation. EIDs may continue to infuse IV fluids after an infiltration has begun. Calculation and regulation of IV flow rates is the responsibility of the nurse. Most electronic infusion devices use microdrip tubing that delivers 60 gtt per minute. When calculated, the milliliters per hour will be the same as the number of gtt per minute. For example, it is essential to monitor the infusion site for infiltration because an infiltration may become quite significant before the EID alarm will sound.

Solve the problem.Order: Lorazepam (Ativan) 6 mg, IV, q6h, as neededMedication available: Lorazepam (Ativan) 4 mg per mLDrug reference: IV maximum infusion rate 2 mg per minuteHow much medication would you administer? ___________ mL

1.5

Calculate the following problem. Remember to round off the answer to the nearest whole number, because fractions of a drop are to be avoided when calculating IV drip rates.Order: 500 mL of D5W in 5 hoursAvailable: Electronic infusion device; 500 mL of D5W, microdrip tubing (drop factor 60 gtt/mL)The electronic infusion device rate is ___________ gtt per minute.

100 500 mL / 5 hours = 100 mL per hour100 mL / 1 × 60 gtt/mL / 60 minutes = 100 gtt per minuteThe setting on the electronic infusion devices (EID) would be 100.

Which of the following demonstrates the best documentation of discontinuation of an IV?

1030 20 Gauge 1 inch (2.5 cm) catheter removed from left forearm. Catheter tip intact. Site without redness, swelling, or bleeding. T. Rodriguez, RN. 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.

The health care provider has ordered levofloxacin (Levaquin) 250 mg in 50 mL to be infused over 1 hour.How many gtt/min will you set the rate on a gravity flow if the drop factor is 15?

13

Which type of dextrose solution would the nurse document as isotonic?

5% in water Dextrose 5% in water is an isotonic solution. Dextrose 10% in water is a hypertonic solution. Dextrose 5% in 0.9% sodium chloride and dextrose 5% in 0.45% sodium chloride are also hypertonic solutions.

Which saline solution draws water from cells into the extra cellular fluid by osmosis?

5% sodium chloride

The health care provider has ordered levofloxacin (Levaquin) 250 mg in 50 mL to be infused over 1 hour. Micro-drip tubing (60 gtts/mL) is being used.The nurse should set the infusion pump at ___________mL/hr.

50

Ordered: 150 mL of IV antibiotic to infuse over 40 minutes. At how many drops/min should the nurse set the rate, if the drop factor is 15 gtt/mL?

56

Calculate the following problem. Remember to round off the answer to the nearest whole number, because fractions of a drop are to be avoided when calculating IV drip rates.Order: 500 mL of D5W in 2 hoursAvailable: 500 mL of D5W; IV macrodrip tubing 15 gtt per milliliterThe patient should receive ___________ gtt per minute.

63 500 mL/2 hour = 250 mL per hour250 mL / 1 × 15 gtt/mL / 60 minutes = 62.5 gtt/min = 63 gtt per minute

Remember to round off the answer to the nearest whole number, because fractions of a drop are to be avoided when calculating IV drip rates.A patient is to receive 1000 mL of 0.45% normal saline over 12 hours. The nurse begins the infusion at 0800. Four hours later, the nurse notes there is 750 mL left in the IV bag. The nurse recalculates the flow rate. The nurse should set the electronic infusion device at ___________mL/hr.

94 12 hours − 4 hours = 8 hours left750 mL / 8 hour = 93.75 = 94 mL/hr

The nurse has received an order to infuse an IV medication. Which of the following would be the safest choice of equipment to use?

A smart pump. Smart pumps contain computer software to prevent errors that relate directly to administration of IV medications. The pump will sound an alarm if the pump setting does not match the medication administration guidelines, assisting in prevention infusion errors.

A vital factor in the care of a peripheral IV infusion is the prevention of infection. Which of the following, if performed by the nurse, would indicate that the nurse requires further instruction in IV fluid therapy management? The nurse:

A vital factor in the care of a peripheral IV infusion is the prevention of infection. Which of the following, if performed by the nurse, would indicate that the nurse requires further instruction in IV fluid therapy management? The nurse: The nurse should not palpate the insertion site after it has been cleansed with a single-use antiseptic solution because this will contaminate the site. The IV site should be allowed to air-dry after a single use antiseptic is applied—30 seconds for chlorhexidine and at least 2 minutes for povidone-iodine solution. The nurse should palpate the IV insertion site daily through the intact dressing to assess for tenderness at the site. The nurse should clean the injection port with a single use antiseptic before accessing the system, whether it be to attach a secondary set or administer an IV push medication

What are the disadvantages of administering medications by intravenous (IV) bolus? (Select all that apply.)

Amount of time allowed for correcting errors Possibility of irritation to the lining of blood vessels. Administering medications by the IV route has advantages. Often the nurse uses the IV route in emergencies. The IV route is also best when it is necessary to establish constant therapeutic blood levels. Some medications are highly alkaline and irritating to muscle and subcutaneous tissue. These medications cause less discomfort when given intravenously. The IV route may be used to deliver medications in a small bolus, which is an advantage for a patient on a fluid restriction. Disadvantages include the IV bolus being the most dangerous method for administering medications because there is a lack of time to correct errors. In addition, a bolus may cause direct irritation to the lining of blood vessels.

What are the advantages of administering medications by intravenous (IV) bolus? (Select all that apply.)

Ability to maintain a patient on a strict fluid restriction. Avoids possible discomfort with highly alkaline medications compared with the subcutaneous or intramuscular (IM) route. Time it takes to achieve constant therapeutic drug levels. Quick route of administration in an emergency; rapid response. Administering medications by the IV route has advantages. Often the nurse uses the IV route in emergencies. The IV route is also best when it is necessary to establish constant therapeutic blood levels. Some medications are highly alkaline and irritating to muscle and subcutaneous tissue. These medications cause less discomfort when given intravenously. The IV route may be used to deliver medications in a small bolus, which is an advantage for a patient on a fluid restriction. Disadvantages include the IV bolus being the most dangerous method for administering medications because there is a lack of time to correct errors. In addition, a bolus may cause direct irritation to the lining of blood vessels.

The nurse is preparing an IV infusion before initiating an IV. Which of the following is a correct action performed by the nurse?

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. 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.

Which of the following are part of maintenance care of a peripheral intravenous site? (Select all that apply.)

Changing IV fluids. Changing IV tubing. Regulating the IV flow rate. Changing the IV dressing. Ongoing assessment. Maintenance of an intravenous site includes continuous assessment, regulation of the rate of flow, changing IV fluid intravenous tubing, and changing the peripheral IV dressing.

Which of the following is a correct sequence for administering a medication by IV bolus through a saline lock?

Clean injection port, insert syringe of normal saline, aspirate for blood return, and flush with saline. Remove syringe, clean port, administer medication over recommended period, withdraw syringe, clean port, and flush port with normal saline at same rate as medication administration. The correct sequence is clean injection port, insert syringe of normal saline, aspirate for blood return, and flush with saline. Remove syringe, clean port, administer medication over recommended period, withdraw syringe, clean port, and flush port with normal saline at same rate as medication administration.

Which are isotonic solutions most commonly used for fluid volume replacement? (Select all that apply.)

D5W LR 0.9% NaCl 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.

Identify advantages of administering medication by the IV route. (Select all that apply.)

Delivers medication quickly in an emergency. Establishes therapeutic blood levels Causes less discomfort with highly alkaline medications that are irritating to subcutaneous or intramuscular tissue. The advantages of administering medication by the IV route are that it provides a route for administering medication when the drug must be delivered quickly, it is the preferred route when it is necessary to establish constant therapeutic blood levels, and it causes less discomfort with highly alkaline and irritating medications than the subcutaneous or intramuscular route. After a medication enters the bloodstream, it begins to act immediately. If the patient is allergic to the medication, the reaction will be more prompt. Administering medications by the IV route requires more knowledge and skill to prevent negative outcomes.

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.)

Determine patency by aspirating for a blood return. Check for kinking of IV tubing. 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.

Which type of intravenous fluid is hypertonic when it first enters a patients vein but has an effective hypotonic concentration after it flows through the vascular system?

Dextrose 10% in water (D10W) D10W is hypertonic when it first enters the patients vein however dextrose enters the cells rapidly, leaving free water, which dilutes the extra cellular fluid. Therefore the effective concentration in the body is hypotonic. D5W is isotonic when it first enters the patients vein, but the effective concentration in the body is hypotonic. An LR solution is isotonic when it first enters the patients vein, the effective concentration in the body is also isotonic. D5NS is hypertonic when it first enters the patients vein but the effective concentration in the body is isotonic.

Which assessment finding is consistent with IV fluid infiltration? Select all that apply.

Edema and pain Pallor and coolness

Which complication involves the entry of an IV solution containing a vesicant drug into the subcutaneous tissue around the venipuncure site?

Extravasation The entry of a vesicant drug into the tissues is called extravasation. Bleeding is a complication associated with this procedure and can sometimes occur especially when patients are on anticoagulants or have a low platelet count. Phlebitis is the inflammation of the inner layer of the vein. Infiltration occurs when IV fluid enters the subcutaneous tissue around the site, similar to extravasation, but does not involve a vesicant drug, such as some chemo therapies.

Which action will the nurse implement when observing symptoms of dyspnea and crackles in the lungs caused by sudden infusion of a large volume of solution?

Temporarily slowing the infusion rate to 10gtt/min Administration of infusion may have unexpected outcomes including dyspnea and crackles in the lungs caused by a sudden infusion of a large fluid volume. The nurse must then slow the infusion rate to 10 gtt/min temporarily and notify the HCP. The nurse must discontinue the present IV and start and new IV line in another extremity when the IV fluid container empties with subsequent loss of vascular access device patency. The nurse must consult the HCP for the new prescription to provide necessary fluid volume when the IV fluid infuses slower than prescribed.

The nurse performed hand hygiene and applied clean gloves to perform an intravenous (IV) tubing change. Which step(s) described in the following was missed or performed incorrectly? Remove IV dressing covering catheter hub and slow rate of infusion to keep-vein-open (KVO) by regulating the roller clamp. Fill drip chamber of old tubing, remove IV container from IV pole, and remove old tubing from the solution. Place insertion spike of new tubing into the old fluid container opening and hang it on the IV pole. Fill tubing rapidly with solution, creating air bubbles in the tubing. Turn roller clamp to the "off" position on the new tubing and remove as much air as possible. Turn roller clamp on the old tubing to the "off" position. Stabilize hub of the catheter, disconnect the old tubing from the catheter hub, and quickly insert adapter of new tubing into catheter hub. Open roller clamp on new tubing, and regulate IV dr

Failing to close the roller clamp on the new tubing before inserting it into the fluid container. The nurse should have closed the roller clamp on the new tubing before inserting it into the fluid container. This would have prevented the fluid from filling the tubing rapidly and creating air bubbles, which had to be removed. If the roller clamp had been closed before placing the insertion spike into the fluid container, the nurse could have slowly opened the roller clamp, allowing the solution to prime the new tubing without creating air bubbles. It is unnecessary to wipe the IV catheter hub with an antiseptic swab when new tubing is connecting directly to the IV catheter. Once the new tubing is connected, the roller clamp should be opened to reestablish the infusion and the rate set according to health care provider's order. The IV dressing should be changed if it becomes wet or soiled.

Which of the following sites should be avoided for intravenous (IV) line insertion? (Select all that apply.)

Foot of an adult. Site distal to a previous venipuncture site. Ventral surface of wrist (inner wrist). Areas of venous bifurcation. 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.

Which clinical criterion of phlebitis should receive a grade of 3?

Formation of streak According to the phlebitis scale, the nurse would give a grade of 3 if there is any streak formation or a palpable venous cord. The nurse would give a grade of 2 if there is only erythema. The nurse would give a grade of 4 if there is a palpable venous cord greater than 2.54 cm (1 inch). Erythema at the access site with or without pain is grade 1.

Which of the following sites should be avoided when initiating an intravenous infusion? (Select all that apply.)

The left arm of a patient who has a history of a left-sided mastectomy. An area of venous bifurcation or palpation of valves. Side of paralysis. 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.

The nurse checks the identity of the patient, performs hand hygiene, and applies clean gloves. The nurse removes the old dressing, cleans the site with CHG solution in a back-and-forth motion, and allows the site to dry. The nurse applies a new manufactured catheter stabilization device, applies a transparent dressing, secures the tubing with tape, and labels the dressing with date and time of dressing change. The nurse discards used equipment and performs hand hygiene. The student nurse observing the nurse change the peripheral IV dressing correctly identifies actions the nurse should have performed. The student nurse is correct in identifying which two actions?

How the dressing was labeled. To stabilize the catheter when removing the old dressing. The nurse should stabilize the catheter when removing the old dressing to prevent accidental displacement of the vascular access device (pulling tape of old dressing one layer at a time in a direction toward the insertion site). The nurse should label the dressing with date and time of insertion, time of dressing change, gauge and length of catheter, and nurse's initials. Clean gloves may be worn. The site was cleaned in the appropriate direction. A commercial catheter stabilization device, transparent dressing, or sterile gauze dressing may be used.

Which equipment will the nurse gather when preparing to initiate a peripheral vascular access device for a patient who requires IV fluid therapy? Select all

IV catheter Tourniquet Clean gloves Occlusive dressing Infusion pump

Which of the following indicate that the infusion needs to be temporarily discontinued, the catheter removed, and the IV relocated?

Insertion site is pale, cool to touch, and extremity edematous. Small amount of purulent drainage is at insertion site; redness is noted. Signs and symptoms of infiltration (i.e., insertion site pale, cool to touch, edema) require the infusion to be temporarily discontinued, the catheter removed, and the IV relocated with a new sterile catheter. Localized infection at the insertion site (redness, purulent drainage) also requires discontinuation of the present IV and relocation. It is unnecessary to relocate the IV site if the patient is afebrile and without symptoms of infection at the IV site. If the catheter is leaking, tightening the tubing and hub connection should be attempted first. Dried blood indicates the need for a dressing change but fails to require IV relocation.

Identify nursing precautions to ensure safe patient care when administering IV medications. (Select all that apply.)

Observing for symptoms of adverse reactions. Following the six rights of medication administration. Being knowledgeable of the desired action and side effects of the medication. Assessing vital signs before, during, and after infusion with potent medications. Verifying the rate of administration with a drug reference or pharmacist. Having the antidote available, if the medication has one. The nurse takes special care to avoid errors in dose calculation and preparation because once the dose enters the bloodstream, it begins to act immediately and there is no way to stop its action. The nurse uses the six rights of medication administration to verify that the right dose of the right medication is given by the right route to the right patient at the right time and then documented accurately. The nurse verifies the prescribed rate of administration with a drug reference or pharmacist before giving any IV medication so that the medication is given over the appropriate amount of time. Patients may experience severe adverse reactions if IV medications are administered too quickly. The nurse is aware of the desired therapeutic effect and potential side effects for accurate observation and evaluation of the medication therapy. The nurse continuously observes the patient for symptoms of adverse reactions so that early intervention may be implemented. This includes having an antidote available if the medication has one. When administering potent medications, the nurse assesses vital signs before, during, and after administration to assess for any alteration in the patient's status. It is inappropriate to delegate nursing assessment and evaluation to assistive personnel. Only add medications to new IV fluid containers as ordered by the health care provider, and administer solutions and medications prepared and dispensed from the

Which of the following would be consistent with phlebitis? (Select all that apply.)

Pain Redness 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.

Which action describes how the nurse will assess for infiltration at the vascular access device site?

Palpating through the intact dressing The nurse should palpate through the intact dressing at the VAD site to assess infiltration symptoms. Palpating can reveal the symptoms of pain and burning. Observing leakage at the site indicates the need to change the dressing immediately. Transparent dressing should not be removed to assess the infiltration. The presence of moisture at the site indicated a risk of contamination and microbial growth.

Which nursing action would be beneficial for a patient receiving intravenous infusion therapy who reports shortness of breath and an increase in the frequency of urination?

Placing the patient in high-Fowler's position A patient who was on intravenous infusion therapy who reports shortness of breath and an increase in the frequency of urination should be placed in high-Fowler's position to promote lung expansion and prevent pulmonary congestion caused by fluid overload. The intravenous fluid rate should be slowed to 10 gtt/min. Starting a new IV line is applicable when vascular access device patency is lost.

An adult patient developed a complication with his IV and it had to be removed, yet continued IV fluids were needed. Which site would be most appropriate for the nurse to choose?

Proximal to the previous IV site. 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.

When preparing to administer an IV medication, a nurse checks the health care provider's order with the medication administration record (MAR) and the label on the medication vial. The nurse verifies the IV route for administration. Next the nurse computes the correct dosage and withdraws the medication according to the MAR using the appropriate dilution. The nurse administers the medication intravenously at the time ordered and at the correct rate. Which of the six rights of medication administration did the nurse fail to demonstrate? (Select all that apply.)

Right patient. Right documentation. The nurse failed to identify the right patient by comparing the MAR to the patient's identification bracelet and asking the patient to state his or her name and birth date. Also the nurse is not described as recording the medication administration on completion of the procedure. Although the right concentration is excluded from the six rights of medication administration, the nurse did demonstrate the right dose by calculating the dosage and preparing it according to the medication order. Right tubing and right date of expiration also are not identified as among the six rights of medication administration. The nurse did verify the right drug by looking at the medication label on the vial and comparing it with the MAR. The nurse would also check the expiration date on the medication label at this time.

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.)

Shortness of breath and crackles in lungs. Elevated blood pressure and edema. 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 complication will be prevented with the nursing action of turning off a patients electronic infusion device, removing the tubing from the device and closing the roller clamp while discontinuing the peripheral access?

Spillage of the IV fluid

Which action indicates a need for further teaching regarding treatment for a blood transfusion reaction?

Stopping the blood and continuing saline solution Performing prompt interventions in a patient who has an unexpected reaction during a blood transfusion restores the patients physiological stability. The nurse must not turn off the blood and simply turn on the 0.9% sodium chloride because this would cause the blood remaining in the IV tubing to infuse into the patient. The nurse must keep the IV line open by replacing the IV thing down the catheter hub with new tubing and running normal saline solution. The nurse must notify the health care provider or emergency response team for further guidance. The nurse must monitor the patients signs and symptoms and vital signs every 5 minutes.

Which of the following situations indicates discontinuation of peripheral intravenous (IV) access? (Select all that apply.)

The patient is being discharged to home on oral (PO) medications The electronic infusion pump keeps alarming, indicating "occlusion" on its screen, and the nurse is unable to flush the IV. The patient's arm is swollen and cool to the touch; the patient complains of pain at the IV site. 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.

If a nurse fails to monitor a patient's intravenous (IV) infusion, what complications could develop? (Select all that apply.)

The patient may experience infiltration. The catheter may clot off. The patient may receive less than the prescribed amount of IV fluids. The patient may receive more than the prescribed amount of IV fluids. If the bag or bottle of IV fluids runs empty, the catheter may become clotted off and patency of the IV will be lost, resulting in the need to restart the IV. A volume-control device helps prevent fluid overload but does not prevent clotting off if the fluids should run dry. If the IV catheter becomes clotted off or the tubing is kinked, the patient may receive less than the prescribed amount of fluids. Without monitoring, the patient may experience undetected infiltration. Electronic infusion devices may continue to infuse IV fluids after an infiltration has begun. If a patient's IV is positional and unmonitored, a patient could accidentally receive more fluids than prescribed, which could result in circulatory overload. If the patient has decreased circulatory blood volume, an IV infusion rate that is too slow can further increase the patient's likelihood of circulatory collapse. An inline filter may prevent particulate matter from entering the patient but does not prevent fluid overload or deficiency. It is inappropriate for assistive personnel to regulate an IV infusion.

Which of the following are advantages of volume-controlled intravenous (IV) infusions? (Select all that apply.)

There is less risk of rapid-dose infusion (as compared with IV push) because medications are diluted and infused over longer time intervals (e.g., 30 to 60 minutes). It allows for administration of medications (e.g., antibiotics) that are stable for a limited time in solution. Using volume-controlled infusions has several advantages: It reduces the risk of rapid-dose infusion by IV push. Medications are diluted and infused over longer time intervals (e.g., 30 to 60 minutes). It allows for administration of medications (e.g., antibiotics) that are stable for a limited time in solution. It allows for control of IV fluid intake. The risk of side effects still remains; the safest method of administering IV medications is by large-volume infusions. IV bolus is the preferred method in an emergency when quick-acting medications are needed.

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.)

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.) D51/2 NS D5LR 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.

The nurse is discontinuing peripheral IV access. Which of the following steps, if performed by the nurse, requires correction?

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 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.

A nurse takes precautions to prevent an undesirable outcome when administering medications by the IV route. Which of the following actions may produce an undesirable outcome? The nurse:

adds piggyback infusion of an antibiotic to main line IV of parenteral nutrition. The nurse should never administer IV medications through tubing that is infusing blood, blood products, or parenteral nutrition solutions because the medications may cause the blood cells to clump or cause clotting. Cultural assessment yields information about dietary preferences, tobacco and alcohol use, and use of herbal remedies that affect drug action and response. Patients may experience severe adverse reactions if IV medications are administered too quickly. Verify the rate of administration with a drug reference or a pharmacist before giving any IV medication to ensure medication is given over the appropriate time in the appropriate concentration. For risk reduction, the nurse should administer solutions and medications prepared and dispensed from the pharmacy or as commercially prepared when possible.

The nurse is planning to administer an IV medication with a mini-infusion pump. The nurse has performed hand hygiene; verified the medication, dose, route, and time with the order; and explained the medication therapy to the patient. The nurse uses two patient identifiers to verify the right patient. The nurse connects the prefilled syringe to the mini-infusion tubing and places the syringe into the mini-infuser pump. The nurse connects the mini-infusion tubing to the main IV line and hangs the pump on the IV pole alongside the primary IV. The nurse set the pump to deliver the medication within the recommended time while allowing the primary line to continue to infuse. The nurse observes the patient for any signs of adverse reactions. What steps have not been completed? The nurse needs to: (Select all that apply.)

gently push the plunger and fill the tubing with medication. check that the syringe was secure in the mini-infuser pump. wipe off the port with an alcohol swab before connecting the mini-infusion tubing to the main IV line press the button on the mini-infusion pump to begin the infusion. The correct sequence for administering an IV medication with a mini-infusion pump is as follows: Check the patient's identification bracelet and ask the patient to state his or her name and one other identifier (identification of the patient is required before any medication administration); connect the prefilled syringe to mini-infusion tubing (tubing must be attached to syringe for infusion); carefully apply pressure to the syringe plunger, allowing the tubing to fill with medication (infusion tubing should be fluid filled and free of air bubbles to prevent air embolism); place the syringe into the mini-infuser pump and be sure the syringe is secure (to facilitate proper administration); wipe off the port with an alcohol swab (to reduce the transmission of microorganisms); connect the mini-infusion tubing to the main IV line and hang the infusion pump with syringe on the IV pole alongside the main IV bag (prevents delay in flushing after completion of infusion, maintaining patency of device); set the pump to deliver medication within the time recommended (for IV medication to be delivered at recommended rate); press button on the pump to begin the infusion. The main IV infusion normally continues to flow while medication infuses; after the medication has infused, check the flow regulator on the primary infusion, and regulate as needed (prevents infusion of excess fluid); observe the patient for signs of adverse reactions (early identification of a medication reaction or complications enables prompt intervention)