Question 1

A nurse is caring for multiple clients with I.V. access devices. The nurse carefully assesses each client for signs of local complications. For which systemic complication should the nurse observe?

Accepted Answer

The nurse should observe for signs of speed shock, a systemic complication that occurs when intravenous fluids or medications are administered too quickly, leading to increased heart rate, shortness of breath, chest pain, and decreased blood pressure. Local complications, such as phlebitis (inflammation of the vein), hematoma (collection of blood), and extravasation (leakage of fluid outside the vein), are important to assess for, but they are not systemic complications.

Question 2

A nurse priming an I.V. administration set uncaps the distal end to attach a needleless device. Before attachment, the administration set falls and hits the countertop. Which action should be taken by the nurse?

Accepted Answer

The administration set should be changed since it fell on the countertop, which could cause contamination. It is important to use sterile equipment during intravenous therapy to prevent infections. Attaching a new needleless device or wiping the tubing port with povidone-iodine may not be sufficient to prevent contamination. Scrubbing the needleless device with an alcohol swab is not necessary in this situation.

Question 3

A nurse assesses a client who is receiving an intermittent I.V. infusion of vancomycin hydrochloride. The nurse notes that the I.V. site is warm, edematous, and indurated. The nurse also observes red streaking of the skin, peau d'orange skin, and vesicles. Based on this information, which condition should the nurse suspect?

Accepted Answer

C

Question 4

A nurse on a medical-surgical unit is caring for multiple clients. Which clients should the nurse monitor closely for signs of phlebitis because they are at increased risk? SELECT ALL THAT APPLY.

Accepted Answer

The answer of A nurse on a medical-surgical unit is...

Question 5

A client who has a central venous tunneled catheter for administration of chemotherapy presents to a hospital with a fluctuating fever, hypotension, profuse sweating, nausea, and explosive diarrhea. Based on this information, which condition should a nurse suspect?

Accepted Answer

The symptoms described indicate septicemia, a potentially life-threatening condition caused by bacterial infection in the bloodstream. The presence of a central venous catheter puts the client at high risk for developing septicemia. Local infection, phlebitis, and superior vena cava syndrome would not typically present with the symptoms described.

Question 6

Upon inspection of a client's peripheral I.V. site, a nurse notes 3+ phlebitis of the client's vein. Which action by the nurse is most appropriate? SELECT ALL THAT APPLY.

Accepted Answer

The answer of Upon inspection of a client's peripheral I.V....

Question 7

A nurse in an intensive care unit is caring for a client who has lipid deposits in her central line. Which agent should the nurse select to instill into the catheter in an attempt to dissolve the lipid deposits?

Accepted Answer

The answer of A nurse in an intensive care unit...

Question 8

A client complains to a nurse that his or her I.V. site is "sore." The nurse notes that the site is red and edematous, but there is no palpable cord or streak. Using the criteria for infusion phlebitis, what should the nurse document as the severity of this phlebitis?

Accepted Answer

According to the criteria for infusion phlebitis, a red and edematous site with no palpable cord or streak is considered a 2+ phlebitis. This indicates a moderate degree of inflammation and may require intervention such as removal and reinsertion of the catheter.

Question 9

A nurse is assisting in the placement of a client's central venous catheter. The nurse is aware that the major complication that can occur during placement of a central venous access device is:

Accepted Answer

The major complication that can occur during placement of a central venous access device is intravascular and extravascular malpositioning, which can lead to improper placement in a vein or artery or even outside the vessel. Phlebitis and infiltration are common complications, but they do not pose as much risk as malpositioning. Fibrin sheath formation is a delayed complication that occurs when fibrin accumulates around the catheter and causes blockage, but it is not as common as malpositioning during placement.

Question 10

A nurse is caring for a client who has lipid deposits occluding his or her central line. Which declotting agent should the nurse use to clear lipid deposits from a central line?

Accepted Answer

70% ethanol is effective in clearing lipid deposits from central lines. Other options like hydrochloric acid, sodium bicarbonate, and alteplase are not specifically used for lipid deposits. Alteplase is commonly used for blood clots, not lipid deposits.

Question 11

A nurse attempts to withdraw a blood sample for laboratory analysis from a central venous catheter (CVC) and is unsuccessful due to an aspiration occlusion. What could potentially be causes of an aspiration occlusion? SELECT ALL THAT APPLY.

Accepted Answer

Catheter migration, a fibrin tail extending from the catheter tip, and the catheter tip being pressed up against the vein wall are all potential causes of an aspiration occlusion, which is a blockage of the catheter that prevents blood from being withdrawn. Chylothorax is not a cause of an aspiration occlusion.

Question 12

Which complication of I.V. therapy should a nurse suspect if a client has a fluctuating fever, chills, malaise, tachycardia, tachypnea, hypotension, and altered mental status?

Accepted Answer

The symptoms described suggest septicemia, which is a serious complication of I.V. therapy characterized by a systemic infection resulting from the spread of bacteria or other microorganisms from a local infection site or contamination of the I.V. catheter or solution. The symptoms listed, such as fever, chills, malaise, tachycardia, and altered mental status, are common manifestations of septicemia. Thrombophlebitis is characterized by inflammation and clot formation in the vein; local infection is limited to the site of I.V. insertion; and inflammatory response syndrome is a state of systemic inflammation without evidence of infection.

Question 13

A nurse in an intensive care unit is caring for a client who has an intraluminal obstruction of central line due to a thrombotic occlusion. Which declotting agent should the nurse select to remove the blood clots from a central line?

Accepted Answer

Alteplase is a thrombolytic agent that dissolves blood clots and is commonly used to declot central lines. Ethanol, sodium chloride, and sodium bicarbonate are not indicated for removing blood clots from central lines.

Question 14

A client who has been discharged from a hospital for 48 hours reports pain at a previous infusion site. On inspection of the site, a nurse finds redness and tenderness along the vein. Which condition should the nurse suspect?

Accepted Answer

Postinfusion phlebitis is characterized by redness and tenderness along the vein at or near the site of an infusion. It can occur up to 48-72 hours after the infusion has ended. This condition is caused by irritation from the catheter, the substance infused, or both. Extravasation is the leakage of infused substances into surrounding tissue, which can cause pain, swelling, and tissue damage. Speed shock is a systemic reaction to a medication that is administered too quickly or in too high a dose, which can cause symptoms such as headache, sweating, and hypotension. Bacterial phlebitis is an infection of the vein, which can cause symptoms such as redness, warmth, and fever. However, the client in this scenario does not exhibit symptoms of infection.

Question 15

A nurse assesses the insertion site of a peripheral I.V. catheter and notes that the site is red, warm to touch, and slightly edematous proximal to the I.V. cannula. The client reports discomfort when the site is touched. The nurse should interpret that these signs are most likely due to:

Accepted Answer

The given signs of redness, warmth, edema, and discomfort at the insertion site of an I.V. catheter often indicate phlebitis, which is an inflammation of the vein. The other options, such as a venous spasm, hypersensitivity to the solution, or infiltration of the solution, may cause different symptoms or signs such as pain, resistance to flow, allergic reactions or swelling away from the insertion site, respectively.

Question 16

A nurse suspects that a client with a peripheral access device is experiencing a venous spasm. Which report by the client should prompt the nurse to suspect this condition?

Accepted Answer

A venous spasm can cause sharp pain that extends from the site of infusion. Redness, coldness, and increased temperature may be indicative of other complications such as infection or phlebitis.

Question 17

A nurse is caring for a client who has a newly implanted port. For which complication, specifically associated with implanted ports, should the nurse observe?

Accepted Answer

The answer of A nurse is caring for a client...

Question 18

Upon inspection of a client's peripheral I.V. site, a nurse notes 2+ phlebitis of the client's vein. Which action by the nurse is most appropriate?

Accepted Answer

Phlebitis is inflammation of a vein, and a 2+ phlebitis indicates moderate inflammation. The most appropriate action is to discontinue the cannula to prevent further damage to the vein and apply heat to the site to decrease inflammation and improve circulation. Watching the site and documenting observations is important but does not address the current issue. Flushing the cannula with saline may be helpful in preventing occlusion but does not address the inflammation. Leaving the cannula in place with heat may also exacerbate the inflammation and is not recommended.

Question 19

A nurse assesses that a client has developed 2+ phlebitis at the site of a current peripheral I.V. infusion. Which action should be the nurse's first priority?

Accepted Answer

Discontinuing the I.V. catheter at the site of phlebitis is the priority intervention as leaving the catheter in place can lead to further complications such as infection, sepsis, and thrombosis. The physician should be notified after the catheter has been discontinued. Starting a new line proximal to the old site may be necessary but it is not the first priority in this situation. Applying warm moist packs may provide comfort but it does not address the issue of phlebitis and should not be the first priority intervention.

Quiz 9: Complications of Infusion Therapy: Peripheral and Central Vascular Access Devices