Question 1

The nurse prepares to relocate an intravenous catheter because of signs of infiltration. The IV was located in the patient's nondominant hand.Which criterion would be best for the nurse to use when deciding on the location of the new intravenous (IV)site?

Accepted Answer

Since an IV site has infiltrated,it is no longer appropriate to use,even though it is on the nondominant extremity.The nurse must now find a site where the vein is of adequate size,location,and pliability and place the IV catheter there.The most distal site is suitable for an original IV site,but it should not be used if an IV line is being reinserted in the same extremity because of possible infusion difficulty,especially when infiltration is present.The nurse avoids inserting the IV catheter at a bifurcation because he or she exposes two vessels to the risks of IV therapy.Although it is ideal to use the patient's nondominant hand,it may not be possible if the prior IV infusion has infiltrated.Injury and pain to the patient could occur.

Question 2

The nurse is caring for a patient with a peripheral intravenous access that is used intermittently for medications but is not a continuous infusion.Which technique should the nurse use for routine care of this peripheral line?

Accepted Answer

Guidelines for the nursing care and maintenance of IV access devices include regular flushes with normal saline solution to assess for and maintain patency since the line is not used constantly.Heparin flushes are not considered routine but are specifically ordered for use in certain patients.The end cap does not need to be changed with every medication dose unless this is agency policy,but it does need to be swabbed with an antiseptic.Routine nursing care of an IV site should prevent phlebitis and infiltration.Changing the IV insertion site daily causes patient discomfort,increases costs,and is contraindicated.

Question 3

The healthcare provider prescribes 500 mL of 0.25% normal saline (1/4 NS)intravenously over 4 hours for the patient.At which rate does the nurse infuse the intravenous (IV)solution into the patient using IV tubing with a drop factor of 15 gtts/mL?

Accepted Answer

500 mL × 1 hr × 15 gtts = 31.25 gtts/min = 31 gtts/min
4 hr 60 min 1 mL

Question 4

The nurse infuses a unit of blood,but after 4 hours the blood infusion is not complete.Which action should the nurse implement?

Accepted Answer

The nurse infuses whole blood within a 4-hour time limit; thus,if the infusion is incomplete at the end of 4 hours,the nurse must discontinue it to decrease the risk of adverse transfusion effects because the blood has warmed sufficiently to promote microorganism growth.Checking the IV access for patency is a reasonable intervention because at the end of 4 hours the IV access is likely to have fibrin deposits or small accumulations that impede infusion rates.Nevertheless the nurse must discontinue the blood infusion because after 4 hours,the blood is not safe to infuse.He or she avoids increasing the infusion rate to complete the transfusion because it increases the risk of fluid volume overload.Although delayed transfusion reactions occur,if a mismatch exists between the blood and the patient,the patient is more likely to manifest reaction within the first few minutes of the transfusion because this is when most transfusion reactions occur.

Question 5

The nurse is trying to access the best insertion site on a patient.Which principle would the nurse use to achieve this goal?

Accepted Answer

The site must be large enough to prevent interruption of venous flow while allowing adequate blood flow around the catheter.The nurse chooses a site for venipuncture with soft,bouncy veins because these veins are more easily punctured and stabilized during the insertion.The most distal vein is the best for insertion to maintain the maximum number of potential sites for future use.The smallest-gauge IV catheter suitable for both the therapy and the patient's vein should be selected.

Question 6

The nurse feels resistance while trying to flush the intravenous (IV)line with a 5-mL syringe of normal saline solution before administering a medication by IV bolus.Which should the nurse implement next?

Accepted Answer

The nurse checks for causes of resistance,such as clamped or kinked tubing.If the IV site is occluded,the nurse discontinues the IV infusion and inserts another IV line in another site.Using a 3-mL syringe increases the potential pressure delivered by the flush.The smaller the syringe,the higher the pressure exerted on the vein.Blood return is a not a sensitive indicator of IV patency; thus the nurse avoids basing follow-up nursing care on the blood return.He or she avoids injecting the medication to prevent complications.

Question 7

After inserting a peripheral intravenous (IV)line into the patient,the nurse provides patient teaching about the IV insertion site.What information should the nurse give to the patient?

Accepted Answer

The nurse instructs the patient to report redness at the insertion site for early detection of IV complications,including infection and phlebitis.The IV site should cause very little discomfort if the infusion is proceeding without problems.Pain associated with an IV infusion indicates vein irritation from infusing fluid,irritating medication,infiltration,extravasatioin,infection,or phlebitis.Patients with IV infusions are not confined to bed.The nurse instructs the patient to call for help when changing the gown because,if the gown has no snaps at the shoulder,the nurse must feed the IV tubing and bag through the opening of the gown when the gown is changed.

Question 8

The patient has an intermittent infusion device inserted in the hand.Which strategy should the nurse use related to prevention of dislodging the patient's intravenous (IV)access?

Accepted Answer

The most important prevention strategy for the nurse to implement is to instruct the patient to protect the IV site by reducing trauma,keeping the IV line in sight,and getting out of bed properly.Less manipulation or trauma to the IV site reduces intravenous irritation and maintains a better seal at the skin to prevent the entry of microorganisms.Daily sterile dressing changes are excessive and may increase the risk of infection and impaired skin integrity.Generally the nurse changes the dressing every 3 days and when needed; however,he or she follows agency policy.Daily flushing of the IV access is inadequate to maintain patency.The nurse changes the IV tubing according to agency policy to prevent infection; however,instructing the patient to participate in access care of the IV line is a more comprehensive prevention strategy.IV access devices require flushing at least 3 times a day with normal saline solution.

Question 9

The nurse is setting up to administer a unit of blood.Which is the most important nursing intervention during preparation for this procedure?

Accepted Answer

Before administering blood,the nurse checks the identification of the patient and the blood product according to agency policy,which includes several patient identifiers.Accurate identification decreases the risk of patient injury,infection,or death from patient-blood mismatch.The nurse prepares the Y-tubing with normal saline before the blood transfusion is started.He or she takes time to teach the patient before beginning the transfusion.The instruction should include when the nurse should be notified; this instruction is given not to alarm the patient but to make the patient an active participant.

Question 10

The nurse is preparing to administer blood.What solution is most appropriate for the nurse to use when priming the blood administration set?

Accepted Answer

The only compatible solution for blood administration is normal saline because it is an isotonic solution.The remaining solutions,especially the dextrose solution,can cause problems with blood administration.

Question 11

The patient has a peripheral infusion for the administration of antibiotics.Which action is most effective for the nurse to use to detect an intravenous (IV)therapy-related infection?

Accepted Answer

The nurse palpates the insertion site gently through the dressing to detect any infection by checking for tenderness or swelling.Removing the dressing exposes the insertion site to contamination from the nurse's contact and environment and risk to the tissues.The nurse uses aseptic technique for IV dressing changes.IV tubing changes every 12 hours are excessive and costly.The nurse applies antimicrobial agents to the insertion site according to agency policy.

Question 12

The nurse assesses the patient's intravenous (IV)insertion site and notes that it is warm,red,and tender.Which intervention should the nurse implement first?

Accepted Answer

The nurse must discontinue the IV infusion with a warm,red,and tender appearance because these clinical indicators are consistent with an infection.The nurse also discontinues the IV infusion to decrease the risk of sepsis,tissue loss,and a thromboembolic event.If the site is infected,slowing the infusion rate is unlikely to help.Cool compress application is an improper therapy for the problem.The nurse applies a warm compress after discontinuing the IV line from the inflamed tissue.

Question 13

The prescription for the patient's intravenous (IV)infusion reads,"100 mL/hr." The nurse observes that the patient's IV line infused 125 mL in addition to the ordered volume after 2 hours.Which is the most important intervention for the nurse to implement?

Accepted Answer

The nurse assesses the patient for respiratory distress after an excessive infusion of 125 mL of IV fluid because excess total body fluid often leaks into the pulmonary vascular bed to decrease gas exchange.This may lead to hypoxemia and dyspnea because the patient has difficulty with oxygenation,and there can be enough fluid overload to precipitate heart failure in a patient with heart disease or respiratory failure in a patient with pulmonary disease.Weighing the patient is a reasonable nursing intervention to differentiate patient weight gain from fluid or caloric intake.Verifying patient safety and well-being is a better choice and is more important than differentiating the weight because the extra fluid can cause dyspnea,desaturation,and heart failure.Checking the infusion pump batteries is a reasonable intervention if the pump operates on battery power. The nurse can reduce the infusion rate to 75 mL/hr after collaborating with the healthcare provider.The nurse cannot change the infusion rate because doing so is equivalent to practicing medicine.

Question 14

The nurse assesses the patient's intravenous (IV)infusion.Which clinical indicator cues the nurse to take special precautions while infusing IV fluids?

Accepted Answer

The nurse scrutinizes IV therapy for patients with crackles in the lungs because it is consistent with clinical indicators of fluid overload and pulmonary edema.In fact,crackles consistently indicate fluid of some type in the lungs and are a classic sign of fluid overload.As a result,the nurse administers IV fluids to the patient with heightened scrutiny to avoid administering excess IV fluids.Poor skin turgor,hypernatremia,and hypotension indicate a potential need for additional fluid volume.

Question 15

The nurse is explaining to nursing assistive personnel (NAP)how to help maintain the patient's intravenous (IV)therapy.What action regarding IV therapy can be delegated to the NAP?

Accepted Answer

The nurse delegates very little to the NAP related to IV therapy.The NAP is expected to report patient complaints to the nurse because he or she receives training to perform this task,however the nurse must determine the meaning of the complaint and how to resolve it.The nurse retains responsibility for adjusting the infusion rate,changing the dressing,and administering IV antibiotics because these nursing tasks require critical thinking and nursing judgment.

Question 16

The nurse observes fine white crystals in the intravenous (IV)tubing that is infusing an antibiotic.Which action should the nurse take?

Accepted Answer

White crystals in IV tubing indicate precipitation of a substance in the infusion,most likely the medication because it is the solute with the highest concentration.If the crystals enter the patient,they can behave like emboli,occluding tiny vessels,and cause regional irritation.At a minimum,the crystals usually occlude the IV line.The nurse stops the infusion,discards the IV tubing,checks to ensure compatibility of all agents in the infusion,and notifies the healthcare provider.The IV access potentially needs to be changed.The nurse avoids telling the patient that this is a common occurrence because it is a complication of an IV infusion.He or she avoids flushing the tubing because injecting a fluid bolus increases the risk of infusing a crystal into the patient.He or she uses an IV filter when indicated for effective therapy.

Question 17

The healthcare provider's order reads,"Administer 5% dextrose solution with normal saline (D₅NS)intravenously now." Which should the nurse implement next?

Accepted Answer

The only recourse for the nurse is to clarify the order because it is incomplete.It is missing an infusion rate. You would not start an IV or give the IV until you have the infusion rate information.

Question 18

The nurse observes that the patient's left cephalic intravenous (IV)site is cool,swollen,and mildly tender,although the IV line is infusing at the prescribed rate.Which action should the nurse take first?

Accepted Answer

The patient's IV site is infiltrated; thus the nurse should discontinue the infusion immediately and start another IV infusion,preferably in the other arm.If the right arm is contraindicated,the nurse chooses a subsequent site that is proximal to the original site to avoid additional irritation of the vein.An infiltrated IV site increases the risk of regional phlebitis.The nurse should collaborate with the healthcare provider to apply a warm,moist compress to facilitate healing and provide comfort once the IV line has been removed.After the nurse discontinues the IV infusion,he or she instructs the patient to elevate the arm to reduce edema because this technique facilitates venous return.

Question 19

The nurse is preparing to insert a peripheral intravenous (IV)line.Which technique should the nurse implement to prepare for the IV insertion?

Accepted Answer

The nurse applies a tourniquet to the patient's arm to engorge the vein selected for IV insertion.This facilitates catheter insertion because a larger vein is easier to enter without transecting the vein than a small vessel.The nurse avoids tapping and massaging the vein before IV insertion because these actions increase the risks of hematoma formation and vasoconstriction.The most distal site on the extremity suitable for IV therapy is selected,and hair around the potential IV insertion site is clipped not shaved,because shaving increases the risks of impaired skin integrity and infection through microabrasions.

Question 20

The nurse prepares to administer blood to the patient.Which is the nurse's priority action?

Accepted Answer

The most critical intervention to administer blood products safely is to accurately identify patient,blood type,cross-match,and blood product because an identification error potentially leads to devastating adverse effects,including hypersensitivity reactions,renal damage,and death.The nurse follows agency policy throughout the process of blood administration to prevent complications from the administration of blood products.Assessing patient vital signs for baseline data is very important for comparison during the transfusion because the data provide the nurse with a basis of comparison to evaluate patient changes.The patient's history of blood donations is irrelevant information unless the donations left the patient grossly anemic.The nurse clarifies any orders when a question develops.Most agency policies do not routinely require confirmation of the infusion rate.

Quiz 27: Intravenous and Vascular Access Therapy

The nurse prepares to relocate an intravenous catheter because of signs of infiltration. The IV was located in the patient's nondominant hand.Which criterion would be best for the nurse to use when deciding on the location of the new intravenous (IV) site?

The nurse is caring for a patient with a peripheral intravenous access that is used intermittently for medications but is not a continuous infusion.Which technique should the nurse use for routine care of this peripheral line?

The healthcare provider prescribes 500 mL of 0.25% normal saline (1/4 NS) intravenously over 4 hours for the patient.At which rate does the nurse infuse the intravenous (IV) solution into the patient using IV tubing with a drop factor of 15 gtts/mL?

The nurse infuses a unit of blood,but after 4 hours the blood infusion is not complete.Which action should the nurse implement?

The nurse is trying to access the best insertion site on a patient.Which principle would the nurse use to achieve this goal?

The nurse feels resistance while trying to flush the intravenous (IV) line with a 5-mL syringe of normal saline solution before administering a medication by IV bolus.Which should the nurse implement next?

After inserting a peripheral intravenous (IV) line into the patient,the nurse provides patient teaching about the IV insertion site.What information should the nurse give to the patient?

The patient has an intermittent infusion device inserted in the hand.Which strategy should the nurse use related to prevention of dislodging the patient's intravenous (IV) access?

The nurse is setting up to administer a unit of blood.Which is the most important nursing intervention during preparation for this procedure?

The nurse is preparing to administer blood.What solution is most appropriate for the nurse to use when priming the blood administration set?

The patient has a peripheral infusion for the administration of antibiotics.Which action is most effective for the nurse to use to detect an intravenous (IV) therapy-related infection?

The nurse assesses the patient's intravenous (IV) insertion site and notes that it is warm,red,and tender.Which intervention should the nurse implement first?

The prescription for the patient's intravenous (IV) infusion reads,"100 mL/hr." The nurse observes that the patient's IV line infused 125 mL in addition to the ordered volume after 2 hours.Which is the most important intervention for the nurse to implement?

The nurse assesses the patient's intravenous (IV) infusion.Which clinical indicator cues the nurse to take special precautions while infusing IV fluids?

The nurse is explaining to nursing assistive personnel (NAP) how to help maintain the patient's intravenous (IV) therapy.What action regarding IV therapy can be delegated to the NAP?

The nurse observes fine white crystals in the intravenous (IV) tubing that is infusing an antibiotic.Which action should the nurse take?

The healthcare provider's order reads,"Administer 5% dextrose solution with normal saline (D₅NS) intravenously now." Which should the nurse implement next?

The nurse observes that the patient's left cephalic intravenous (IV) site is cool,swollen,and mildly tender,although the IV line is infusing at the prescribed rate.Which action should the nurse take first?

The nurse is preparing to insert a peripheral intravenous (IV) line.Which technique should the nurse implement to prepare for the IV insertion?

The nurse prepares to administer blood to the patient.Which is the nurse's priority action?

Quiz 27: Intravenous and Vascular Access Therapy

The nurse prepares to relocate an intravenous catheter because of signs of infiltration. The IV was located in the patient's nondominant hand.Which criterion would be best for the nurse to use when deciding on the location of the new intravenous (IV) site?

The nurse is caring for a patient with a peripheral intravenous access that is used intermittently for medications but is not a continuous infusion.Which technique should the nurse use for routine care of this peripheral line?

The healthcare provider prescribes 500 mL of 0.25% normal saline (1/4 NS) intravenously over 4 hours for the patient.At which rate does the nurse infuse the intravenous (IV) solution into the patient using IV tubing with a drop factor of 15 gtts/mL?

The nurse infuses a unit of blood,but after 4 hours the blood infusion is not complete.Which action should the nurse implement?

The nurse is trying to access the best insertion site on a patient.Which principle would the nurse use to achieve this goal?

The nurse feels resistance while trying to flush the intravenous (IV) line with a 5-mL syringe of normal saline solution before administering a medication by IV bolus.Which should the nurse implement next?

After inserting a peripheral intravenous (IV) line into the patient,the nurse provides patient teaching about the IV insertion site.What information should the nurse give to the patient?

The patient has an intermittent infusion device inserted in the hand.Which strategy should the nurse use related to prevention of dislodging the patient's intravenous (IV) access?

The nurse is setting up to administer a unit of blood.Which is the most important nursing intervention during preparation for this procedure?

The nurse is preparing to administer blood.What solution is most appropriate for the nurse to use when priming the blood administration set?

The patient has a peripheral infusion for the administration of antibiotics.Which action is most effective for the nurse to use to detect an intravenous (IV) therapy-related infection?

The nurse assesses the patient's intravenous (IV) insertion site and notes that it is warm,red,and tender.Which intervention should the nurse implement first?

The prescription for the patient's intravenous (IV) infusion reads,"100 mL/hr." The nurse observes that the patient's IV line infused 125 mL in addition to the ordered volume after 2 hours.Which is the most important intervention for the nurse to implement?

The nurse assesses the patient's intravenous (IV) infusion.Which clinical indicator cues the nurse to take special precautions while infusing IV fluids?

The nurse is explaining to nursing assistive personnel (NAP) how to help maintain the patient's intravenous (IV) therapy.What action regarding IV therapy can be delegated to the NAP?

The nurse observes fine white crystals in the intravenous (IV) tubing that is infusing an antibiotic.Which action should the nurse take?

The healthcare provider's order reads,"Administer 5% dextrose solution with normal saline (D5NS) intravenously now." Which should the nurse implement next?

The nurse observes that the patient's left cephalic intravenous (IV) site is cool,swollen,and mildly tender,although the IV line is infusing at the prescribed rate.Which action should the nurse take first?

The nurse is preparing to insert a peripheral intravenous (IV) line.Which technique should the nurse implement to prepare for the IV insertion?

The nurse prepares to administer blood to the patient.Which is the nurse's priority action?

The healthcare provider's order reads,"Administer 5% dextrose solution with normal saline (D₅NS) intravenously now." Which should the nurse implement next?