Question 1

While assessing the patient's intravenous (IV)infusion,the nurse notes that it is infusing more slowly than it should be.What should the nurse do first?

Accepted Answer

Check the patient for positional changes that might affect infusion rate,height of the intravenous (IV)container,and tubing obstruction.Check the condition of the site.The most likely cause of a slow-running IV is positioning.An infiltrated or clotted IV line probably will not be running at all.Discontinue the IV if it is determined that it is infiltrated or clotted off.Position will affect flow even if rate is increased.Fluid overload is not associated with slowing of the infusion rate.Often it occurs when an IV is running too quickly.

Question 2

The nurse is caring for a patient diagnosed with pneumonia who receives intravenous (IV)antibiotics every 8 hours.How often should the nurse change the primary intermittent IV sets?

Accepted Answer

The nurse should change primary intermittent sets every 24 hours because the intravenous (IV)system becomes interrupted,which increases the risk for contamination.

Question 3

Established standards for routine replacement of peripheral IV catheters and intravenous administration sets have recommended a maximum of _____ hours to reduce intravenous (IV)fluid contamination and prevent catheter site complications.

Accepted Answer

Established standards for routine replacement of peripheral intravenous (IV)catheters and intravenous administration sets have recommended a maximum of 96 hours to reduce IV fluid contamination and prevent catheter site complications.

Question 4

Which of the following steps is necessary when a patient is prepared for intravenous (IV)catheter insertion?

Accepted Answer

Apply a flat tourniquet around the arm,above the antecubital fossa or 10 to 15 cm (4 to 6 inches)above the proposed insertion site.Do not shave the area.Shaving may cause microabrasions and may predispose to infection.Use the most distal site in the nondominant arm,if possible.Vigorous friction and multiple taping of the veins,especially in older adults,may cause hematoma and/or venous constriction.

Question 5

The nurse is assisting the physician during the insertion of a central line into the subclavian vein.How should the nurse cleanse the area?

Accepted Answer

Antiseptics such as chlorhexidine remove resident and transient bacteria.Alcohol should not be applied after the application of iodophor solution.Chlorhexidine is scrubbed in a back and forth motion for 30 seconds.Allow the antimicrobial solution to air-dry completely.This ensures maximum antimicrobial effect.

Question 6

The patient has intravenous (IV)therapy ordered to infuse at 1000 mL over 10 hours.The infusion set has a calibration of 15 gtt/mL.At which rate does the nurse regulate the infusion?

Accepted Answer

Select one of the following formulas to calculate drop rate based on drops per minute: mL/hr/60 min = mL/min followed by Drop factor×mL/min = Drops/min,or mL/hr×Drop factor/60 min = Drops/min.

Question 7

What should the nurse do once she recognizes that the patient has phlebitis at his intravenous (IV)catheter site?

Accepted Answer

Phlebitis is indicated by pain,increased skin temperature,and erythema along the path of the vein.Stop the infusion and discontinue the intravenous (IV)catheter.Start a new IV if continued therapy is necessary.Place a moist warm compress over the area of phlebitis.Document the degree of phlebitis and nursing interventions per agency policy and procedure.The extremity is elevated for an infiltration to reduce edema.

Question 8

The nurse needs to specifically prevent air emboli that may result from intravenous (IV)therapy.What should the nurse make sure to do to prevent air emboli?

Accepted Answer

Prime the infusion tubing by filling it with intravenous (IV)solution.Be certain that the tubing is clear of air and air bubbles.Large air bubbles can act as emboli.A needleless system does not specifically prevent the introduction of air emboli.Medication incompatibility may lead to crystallization of the medication and may cause emboli to form from precipitate.It will not lead,however,to air embolism.Catheter size does not contribute to emboli formation.

Question 9

Which patient would a nurse anticipate would be a candidate for a peripherally inserted central catheter (PICC)?

Accepted Answer

When a child is critically ill or when long-term intravenous (IV)access is anticipated,a PICC catheter,a Broviac catheter,or an implanted port may be used to access a larger vein.PICCs can be used to infuse IV fluids,parenteral nutrition,blood and blood products,and medications such as antibiotics.Gerontological veins are very fragile,with less subcutaneous support tissue and with thinning of the skin.In older patients,use the smallest gauge possible.For example,a 22-gauge needle is adequate for fluid and medication therapy.PICC lines are not inserted routinely.PICCs are used when long-term IV therapy is needed.

Question 10

The nurse is caring for a patient receiving antineoplastic medications intravenously.The nurse discovers that the intravenous site is red,edematous,and painful.The nurse knows that antineoplastic medications are vesicant medications and documents that the patient has experienced which of the following events?

Accepted Answer

When a vesicant medication infiltrates the tissue,this is called an extravasation.Occlusion refers to a thrombus or fibrin sheath that impedes the flow of intravenous (IV)fluids.Phlebitis occurs with redness surrounding the vein,and extravasation leads to trauma within the vein.Thrombophlebitis occurs when trauma occurs within a vein due to a thrombus.

Question 11

While assessing the patient,the nurse recognizes that special caution should be taken with the intravenous (IV)infusion because of fluid volume excess when the nurse notes the presence of which condition?

Accepted Answer

Auscultation of crackles or rhonchi in the lungs may signal fluid buildup in the lungs caused by fluid volume excess.Poor skin turgor is common with fluid volume deficit.The pinched skin stays elevated for several seconds (tenting).This may be an indication of the need for IV therapy.Decreased blood pressure may indicate fluid volume deficit caused by a decrease in stroke volume.This may indicate the need for intravenous (IV)therapy.Dry skin and mucous membranes may indicate dehydration.

Question 12

A pediatric patient has an intravenous (IV)catheter with microdrip tubing.The order is for 40 mL/hr to infuse.At what rate does the nurse set the microdrip?

Accepted Answer

Select one of the following formulas to calculate drop rate based on drops per minute: mL/hr/60 min = mL/min followed by Drop factor×mL/min = drops/min,or mL/hr×Drop factor/60 min = Drops/min.In this case,40 mL/hr×60 gtt/mL = 240 gtt/hr×1 hr/60 min = 40 gtt/min.When microdrip is used,mL/hr always equals gtt/min.

Question 13

What is an appropriate technique for the nurse to implement when changing the dressing at a peripheral intravenous (IV)catheter site?

Accepted Answer

Keep one finger over the catheter at all times until the tape or dressing secures placement.If the patient is restless or uncooperative,it is helpful to have another staff member assist with the procedure.Perform hand hygiene.Apply disposable gloves.Apply the final swab in a circular pattern,moving outward from the insertion site.Do not tape over the connection of the access tubing or port to the IV catheter.

Question 14

What should the nurse do upon noting bleeding around a dressing at an intravenous (IV)catheter insertion site?

Accepted Answer

When blood appears on the dressing,verify that the system is intact,and change the dressing.The intravenous (IV)catheter should be discontinued in the event of infiltration or phlebitis.If bleeding occurs around the venipuncture site and the catheter is within the vein,gauze dressing may be applied over the site.Be aware that if gauze dressing is used,it must be removed to accurately assess the insertion site.Elevation is used in cases of infiltration to reduce edema.Warm compresses are used in cases of phlebitis.

Question 15

What should the nurse do when discontinuing a peripheral intravenous (IV)catheter?

Accepted Answer

Inspect the catheter for intactness after removal,noting tip integrity and length.Place clean sterile gauze above the site,and withdraw the catheter,using a slow,steady motion.Keep the hub parallel to the skin.Do not raise or lift the catheter before it is completely out of the vein,to avoid trauma or hematoma formation.Apply pressure to the site for 2 to 3 minutes,using a dry,sterile gauze pad.Secure with tape.Note: Apply pressure for 5 to 10 minutes if the patient is taking anticoagulants.

Question 16

The nurse caring for a patient receiving intravenous (IV)fluids knows that the current recommendation for changing the tubing on a continuously running IV is:

Accepted Answer

Intravenous tubing administration sets remain sterile for 96 hours.Thus,the Infusion Nurses Society (INS)recommends changing tubing no more frequently than every 96 hours.When possible,schedule tubing changes when it is time to hang a new IV container.

Question 17

What should be the next action by the nurse once an over-the-needle catheter (ONC)has been inserted through the skin and into the vein?

Accepted Answer

Observe for blood return through the flashback chamber of the catheter or the tubing of the winged cannula,indicating that the bevel of the needle has entered the vein.Lower the needle until almost flush with the skin.Advance the catheter another 1/8 to 1/4 inch into the vein,and then loosen the stylet site on the over-the-needle catheter (ONC).Only after the catheter is advanced and is in its final position is the catheter stabilized with one hand while the tourniquet is released.Only after the blood and the needle are observed to advance another 1/8 to 1/4 inch into the vein is the stylet loosened.At that point,continue to hold the skin taut,and advance the catheter into the vein until the hub rests at the venipuncture site.

Question 18

The order is for the patient to receive 500 mL over 4 hours.The nurse has an electronic infusion device (EID)in place that provides for the regulation of hourly infusion.The intravenous (IV)tubing available is 10 gtt/mL.What is the setting for the infusion device?

Accepted Answer

For use of electronic infusion device (EID)for infusion,turn on the power button,select the required drops per minute or volume per hour,close the door to the control chamber,and press the start button.In this case,500 mL/4 hr = 125 mL/hr.

Question 19

The patient is expected to require intravenous therapy for several years as treatment for a chronic disease process.Which of the following would be the best choice for venous access in this patient?

Accepted Answer

Implanted infusion ports are used for long-term and complex intravenous (IV)infusion therapy.When not in use,no external catheter is present,and port manufacturers recommend that the port be heparinized every 4 weeks to maintain patency.No other care is required for an unused port.PICCs provide alternative IV access when the patient requires intermediate-length venous access (greater than 7 days to several months).These catheters are used for shorter placements (e.g. ,5 to 10 days).Use of peripheral IV therapy increases the risk for patients to develop infection,vein sclerosis,phlebitis,and infiltration.

Question 20

The nurse is caring for a patient receiving intravenous therapy.The nurse should report which of the following to the primary care provider?

Accepted Answer

If a patient suffers an extravasation,the primary care provider should be notified as soon as possible because complications of some vesicants can be reduced by injection of specific medications,whereas others require rapid medical intervention.It is not necessary to report when you routinely initiate or complete intravenous (IV)therapy.Primary care providers do not need to be notified of a small infiltrate,but it should be documented in the patient's medical record,and your agency may require completion of an event reporting form.

Quiz 29: Intravenous and Vascular Access Therapy

While assessing the patient's intravenous (IV) infusion,the nurse notes that it is infusing more slowly than it should be.What should the nurse do first?

The nurse is caring for a patient diagnosed with pneumonia who receives intravenous (IV) antibiotics every 8 hours.How often should the nurse change the primary intermittent IV sets?

Established standards for routine replacement of peripheral IV catheters and intravenous administration sets have recommended a maximum of _____ hours to reduce intravenous (IV) fluid contamination and prevent catheter site complications.

Which of the following steps is necessary when a patient is prepared for intravenous (IV) catheter insertion?

The nurse is assisting the physician during the insertion of a central line into the subclavian vein.How should the nurse cleanse the area?

The patient has intravenous (IV) therapy ordered to infuse at 1000 mL over 10 hours.The infusion set has a calibration of 15 gtt/mL.At which rate does the nurse regulate the infusion?

What should the nurse do once she recognizes that the patient has phlebitis at his intravenous (IV) catheter site?

The nurse needs to specifically prevent air emboli that may result from intravenous (IV) therapy.What should the nurse make sure to do to prevent air emboli?

Which patient would a nurse anticipate would be a candidate for a peripherally inserted central catheter (PICC) ?

While assessing the patient,the nurse recognizes that special caution should be taken with the intravenous (IV) infusion because of fluid volume excess when the nurse notes the presence of which condition?

A pediatric patient has an intravenous (IV) catheter with microdrip tubing.The order is for 40 mL/hr to infuse.At what rate does the nurse set the microdrip?

What is an appropriate technique for the nurse to implement when changing the dressing at a peripheral intravenous (IV) catheter site?

What should the nurse do upon noting bleeding around a dressing at an intravenous (IV) catheter insertion site?

What should the nurse do when discontinuing a peripheral intravenous (IV) catheter?

The nurse caring for a patient receiving intravenous (IV) fluids knows that the current recommendation for changing the tubing on a continuously running IV is:

What should be the next action by the nurse once an over-the-needle catheter (ONC) has been inserted through the skin and into the vein?

The order is for the patient to receive 500 mL over 4 hours.The nurse has an electronic infusion device (EID) in place that provides for the regulation of hourly infusion.The intravenous (IV) tubing available is 10 gtt/mL.What is the setting for the infusion device?

The patient is expected to require intravenous therapy for several years as treatment for a chronic disease process.Which of the following would be the best choice for venous access in this patient?

The nurse is caring for a patient receiving intravenous therapy.The nurse should report which of the following to the primary care provider?