Question 1

The nurse attempts to secure and stabilize an IV catheter and dressing of an older adult client.Which nursing action is appropriate?

Accepted Answer

Applying a skin protector solution prior to dressing the IV site can help protect the older adult's skin, which may be more fragile and susceptible to damage from adhesives. This practice can enhance the adhesion of the dressing without causing skin injury. Options A, C, and D are not recommended because they can either interfere with the visibility of the IV site, potentially damage fragile skin, or compromise the sterility and adherence of the dressing.

Question 2

The nurse is caring for a client who is receiving intravenous therapy with an infusion pump.An occlusion alarm sounds.Which things will the nurse check? Select all that apply.

Accepted Answer

A,B,C,D

Question 3

The nurse prepares to administer a medication through the client's central line.Per hospital policy,the nurse must use heparin to keep the line patent.Place the steps in the correct order for administering medication through the central line.
A)Administer the medication.
B)Flush the catheter with 5-mL saline.
C)Flush the catheter with heparin.
D)Flush the catheter with 10-mL saline.

Accepted Answer

D,A,B,C

Question 4

The nurse administers intravenous fluid therapy using a Dial-A-Flo device.What is a disadvantage of this device that the nurse recognizes?

Accepted Answer

Dial-A-Flo devices do not control the size of the drops delivered, which can affect the accuracy of the flow rate.

Question 5

The nurse removes a client's intravenous catheter and notes the tip of the catheter is broken.The nurse palpates the client's arm and feels the broken piece.Which action should the nurse take?

Accepted Answer

Applying a tourniquet above the insertion site is the correct action to prevent the broken piece of the catheter from traveling further into the client's circulation, which could lead to serious complications. This action helps to localize the fragment for easier retrieval and prevents it from causing harm elsewhere in the vascular system.

Question 6

After removing a client's intravenous catheter from the upper extremity,the nurse notes the client has persistent bleeding despite applying firm pressure.Which action will the nurse take?

Accepted Answer

Holding the client's arm above the level of the heart helps reduce blood flow to the area due to gravity, which can aid in controlling the bleeding.

Question 7

The nurse plans teaching for the client on methods of encouraging fluid intake.Which statements will the nurse include? Select all that apply.

Accepted Answer

The answer of The nurse plans teaching for the client...

Question 8

The nurse cares for a client who is sedated,intubated,mechanically ventilated,and has a central line.While repositioning the client,the central line is disrupted.Place the steps in correct order in response to the clinical scenario.
A)Place the client in supine position.
B)Clamp the affected lumen with a soft-tipped clamp.
C)Place a strip of tape over the catheter.
D)Notify the health care provider.

Accepted Answer

The answer of The nurse cares for a client who...

Question 9

The nurse prepares to insert an intravenous catheter in an older adult client.Which action should the nurse take?

Accepted Answer

In older adults, veins may be more fragile, so starting with a distal vein allows for subsequent attempts to move proximally if needed.

Question 10

Calculate the flow rate of the following intravenous therapy prescription: 3 liters 09.% normal saline over 24 hours.

Accepted Answer

To calculate the flow rate, divide the total volume (3 liters or 3000 mL) by the total time in hours (24 hours). 3000 mL / 24 hours = 125 mL/hr.

Question 11

The nurse prepares to change the client's central line dressing and replace the injection cap.Which position will the nurse place the client?

Accepted Answer

Placing the client in a supine position during the change of a central line dressing and replacement of the injection cap helps prevent air from entering the central line, reducing the risk of air embolism.

Question 12

The nurse is teaching a client on the importance of monitoring intake and output at home.Which statement will the nurse include in the client teaching?

Accepted Answer

The answer of The nurse is teaching a client on...

Question 13

The nurse cares for a client with a triple lumen central line who develops a fever,which the nurse suspects is from the central line.Which nursing actions are appropriate? Select all that apply.

Accepted Answer

The answer of The nurse cares for a client with...

Question 14

A nurse attempts to flush the lumen of a triple lumen central catheter and notes severe resistance to flushing.Which diagnostic procedure does the nurse anticipate when assessing the correct placement of the central line?

Accepted Answer

A chest X-ray is commonly used to assess the correct placement of a central line and to check for complications such as misplacement or pneumothorax.

Question 15

The nurse cares for a client with an intravenous infusion of D5NS.Which complications will the nurse closely monitor the client for? Select all that apply.

Accepted Answer

D5NS (5% dextrose in normal saline) can lead to increased serum sodium and chloride due to the saline content. It can also cause fluid overload, especially in clients with compromised renal or cardiac function.

Question 16

A novice nurse performs care of a client's central line.Which action by the novice nurse requires intervention by the nurse preceptor?

Accepted Answer

Transparent dressings over central lines should be changed every 7 days unless they are soiled or loose, not every 72 hours. This is a deviation from standard guidelines, which recommend longer intervals between changes for transparent dressings to reduce the risk of infection.

Question 17

The nurse is setting up an intravenous infusion for a client and the nurse has set the IV pump according to the health care provider's orders.How will the nurse best verify that the drops/minute rate is correct?

Accepted Answer

Counting the drops in the drip chamber for 15 seconds and then multiplying by 4 gives an accurate measure of the drops per minute, providing a quick and effective way to verify the correct flow rate.

Question 18

The nurse prepares to change the client's central line dressing.Place the steps of the procedure in correct order.
A)Remove the old dressing.
B)Remove and discard gloves;perform hand hygiene.
C)Don a mask and have the client don a mask.
D)Apply the new dressing.
E)Cleanse the site.

Accepted Answer

The answer of The nurse prepares to change the client's...

Question 19

The nurse cares for a client with a central venous catheter.Which action by the nurse is incorrect when maintaining the client's central line?

Accepted Answer

Using a 5-mL syringe to flush a central venous catheter is incorrect because smaller syringes can generate higher pressure, potentially damaging the catheter or causing catheter rupture. Larger syringes, typically 10 mL or greater, are recommended to ensure lower pressure during flushing.

Question 20

The nurse is assisting the health care provider insert a central line for the client.During the procedure,the client reports sudden shortness of breath and the client's SpO2 falls to 88% on room air.Which actions will the nurse take? Select all that apply.

Accepted Answer

The answer of The nurse is assisting the health care...

Quiz 5: Fluids and Electrolytes