Deck 7: Nursing Care of Patients Receiving Intravenous Therapy

Question 1

A patient is in the intensive care unit with acute renal failure secondary to septic shock and is receiving intravenous fluids of 0.9% NaCl at 125 mL/hr. The patient develops crackles in the lungs, distended neck veins, 1+ pitting edema in the feet, and a 4-pound weight gain from the previous day. What nursing diagnosis is most appropriate to this situation?

A)Imbalanced nutrition: greater than body requirements
B)Excess fluid volume
C)Decreased cardiac output
D)Ineffective tissue perfusion: peripheral

Answer 1

Excess fluid volume

Question 2

The nurse is observing a student change the dressing on a central line. Which of the following actions requires an immediate intervention?

A)The student dons a mask and gloves when changing the dressing.
B)The student instructs the patient to perform Valsalva's maneuver when the line is disconnected for a tubing change.
C)The student places a sticker with the date, time, and initials on the dressing.
D)The student positions the patient on the left side with head down to perform the procedure.

Answer 2

The student positions the patient on the left side with head down to perform the procedure.

Question 3

The nurse assesses a patient receiving intravenous therapy and suspects fluid overload. Which of the following assessments should the nurse perform first?

A)Assess lung sounds for crackles.
B)Inspect the insertion site for infiltration.
C)Check the patient's weight.
D)Observe the patient's feet for edema.

Answer 3

Assess lung sounds for crackles.

Question 4

The LPN enters a patient's room and notes a white precipitate forming in the IV tubing at the site where an antibiotic is piggybacked in. Which of the following actions is appropriate first?

A)Call the pharmacy to see whether this is an expected reaction.
B)When the infusion is complete, remove the tubing, and send it to the laboratory for analysis.
C)Stop the infusion.
D)Notify the physician.

Question 5

An intravenous infusion is not running. The insertion site looks normal. Which of the following actions by the nurse is appropriate to try to get it running again?

A)Flush the catheter with 1 to 2 mL of heparin flush solution.
B)Flush the catheter with 1 to 2 mL of normal saline solution.
C)Reposition the extremity.
D)Place gentle pressure on the bag of solution.

Question 6

As soon as the nurse begins to insert an intravenous catheter in the patient's antecubital space, blood begins to spurt from the site. What should the nurse do first?

A)Finish threading the catheter quickly, and apply a pressure dressing and tape.
B)Remove the catheter, and insert a new one in the same site.
C)Remove the catheter, and apply pressure to the site.
D)Remove the catheter, and call for help.

Question 7

When assessing a patient with an intravenous line in the right arm, the LPN notices that the skin near the infusion site is taut and cool, and when the arm is lowered, it appears to swell. What is most likely occurring?

A)Infection
B)Venous spasm
C)Infiltration
D)Embolism

Question 8

An intravenous (IV) insertion site begins to leak. The tape over the site is wet. What should the nurse do first?

A)Call the physician to report the problem.
B)Remove the dressing from the IV site, and observe the insertion site.
C)Slowly increase the speed of the IV drip, and watch the site carefully for increased leaking of IV solution.
D)Reduce the IV flow rate.

Question 9

An angiocatheter site in a patient's left forearm has become reddened and tender. What should the nurse do first?

A)Check for a blood return.
B)Apply a warm compress over the insertion site.
C)Remove the angiocatheter.
D)Run the intravenous solution at a slightly faster rate to encourage sluggish circulation.

Question 10

At a monthly staff meeting, the nurse manager announces that all central line insertion and dressing kits will now come bundled with 2% chlorhexidine gluconate for site preparation and cleansing. Which evidence best supports this decision?

A)The use of 2% chlorhexidine gluconate reduces hospital costs by 7%.
B)Chlorhexidine-containing antiseptic regimen compared to povidone-iodine or alcohol for catheter insertion sites reduces catheter-related infection by 49%.
C)The company that supplies intravenous and central line catheter equipment has recently changed the product bundling to include 2% chlorhexidine gluconate.
D)The chief of surgery is interested in performing a direct comparison study examining infection rates associated with long-term access devices as they are related to length of time the catheters are in place.Multiple Response
Identify one or more choices that best complete the statement or answer the question.

Question 11

A patient has been on total parenteral nutrition (TPN) for 3 weeks after an episode of severe gastrointestinal bleeding. The physician plans to discontinue TPN. What order should the nurse anticipate?

A)Start tube feedings TID via nasogastric tube.
B)Place the patient on clear liquids for 1 week.
C)Taper TPN rate and introduce regular feedings slowly.
D)Sodium-restricted diet with high-protein snacks bid.

Question 12

A patient is receiving an intravenous (IV) solution delivered by an electronic control device. The alarm begins sounding, and the display panel indicates occlusion. The nurse pushes the alarm silence button, but the alarm quickly resumes. Which of the following actions should be taken first?

A)Notify the physician.
B)Check for kinking of the tubing or a closed clamp.
C)Turn off the IV solution, and gently flush the line with 3 mL of saline flush solution.
D)Decrease the rate to 10 mL/hr, and flush the line with 1 mL of heparin solution.

Question 13

When an intravenous catheter is being inserted on a newly admitted 22-year-old patient, which area should be used first?

A)Upper arm
B)Antecubital space
C)Forearm
D)Hand

Question 14

What type of solution is used to replace electrolytes and expand plasma volume?

A)Isotonic solution
B)Hypotonic solution
C)Hypertonic solution
D)Dextrose solution

Question 15

When is it appropriate to use the SASH (saline-administer medication-saline-heparin) technique for administering intravenous (IV) medications?

A)When the medication is not compatible with heparin
B)When the patient is allergic to heparin
C)During routine peripheral locking device IV flushes
D)When the IV site is red or puffy

Question 16

Which technique best dilates a vein for venipuncture?

A)Elevate the extremity for 5 minutes.
B)Apply a cool compress for 15 minutes.
C)Apply a tourniquet for up to 3 minutes.
D)Apply an alcohol swab for 60 seconds.

Question 17

A patient in an outpatient oncology clinic is going to have a PICC line placed, and wants to know what that means. What is the best response by the nurse?

A)"A PICC line is a catheter that is inserted into your jugular vein and ends in the central circulation."
B)"A PICC line is just a regular IV, but an extra-small catheter is used to prevent vein irritation."
C)"A PICC line is a percutaneous intravenous core catheter."
D)"A PICC line is an intravenous device that is inserted into your arm and ends in the circulation near your heart."

Question 18

Which of the following factors can slow the flow rate of a gravity solution?

A)Raising the level of the solution container
B)Opening the roller clamp
C)Flexing the extremity above the insertion site
D)Flushing the cannula with saline solution

Question 19

Which fluid shift occurs when a hypertonic intravenous solution is administered?

A)Fluid moves from the venous circulation into the interstitial space.
B)Fluid moves from the interstitial space into the venous circulation.
C)Fluid moves from the arterial circulation into the venous circulation.
D)Fluid moves from the plasma into the cells.

Question 20

Assessment of blood glucose levels is prescribed every 6 hours for a patient who is receiving total parenteral nutrition (TPN). The patient asks why this is necessary. Which of the following responses by the nurse is most appropriate?

A)"When people receive TPN, they develop mild diabetes, which needs to be well regulated."
B)"TPN contains a lot of sugar. We monitor blood glucose to be sure it doesn't get too high."
C)"There is a lot of sugar in the solution, which can increase the risk for rebound hypoglycemia."
D)"We have to monitor your glucose because the physician prescribed it."

Question 21

A nurse is infusing an intravenous antibiotic medication. It is ordered as 100 mg in 50 mL D5W to be infused over 20 minutes. How many drops per minute should be delivered using tubing that delivers 15 gtt per mL? ________________drops per minute

Question 22

The nurse is preparing to start a peripheral IV infusion. Which of the following techniques could be used to help ensure success with the venipuncture? (Select all that apply.?

A)Elevate the extremity to promote venous return.
B)Apply a warm compress prior to site preparation.
C)Use a tourniquet to dilate the vein.
D)Lower the head of the bed to reduce cardiac output.
E)Encourage the patient to open the hand and lay it flat on the bed.
F)Push the skin toward the intended puncture site to prevent rolling.Completion
Complete each statement.

Question 23

Why should an intermittent catheter be flushed regularly? (Select all that apply.?

A)To prevent the mixing of incompatible medications and solutions
B)To ensure the patency of the catheter
C)To prevent the formation of emboli
D)To open an occluded catheter
E)To replace lost fluids
F)To provide electrolyte replacement

Question 24

Which patients are most likely to need continuous intravenous therapy? (Select all that apply.?

A)A 3-year-old who has had frequent diarrhea and vomiting for 3 days
B)A patient with pitting edema and lung crackles
C)An 85-year-old man with Alzheimer's disease who refuses to eat or drink
D)A 16-year-old girl with anorexia who has been repeatedly purging
E)A 45-year-old woman with a broken humerus

Question 25

A patient is to receive normal saline 1,000 mL over 6 hours. How many mL per hour should the nurse set on the pump? ________________mL per hour

Question 26

Which of the following are systemic complications of peripheral intravenous therapy? (Select all that apply.?

A)Fluid overload
B)Air embolism
C)Phlebitis
D)Septicemia
E)Extravasation
F)Infiltration