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

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?

A) Phlebitis
B) Hematoma
C) Speed shock
D) Extravasation

Answer 1

C

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?

A) Attach a new needleless device.
B) Change the administration set.
C) Wipe the tubing port with povidone-iodine.
D) Scrub the needleless device with an alcohol swab.

Answer 2

B

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?

A) Occlusion
B) Septicemia
C) Extravasation
D) Thrombophlebitis

Answer 3

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.

A) Client with burns
B) Client who is immunosuppressed
C) Clients receiving total parenteral nutrition (TPN)
D) Client who had multiple I.V. manipulations

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?

A) Local infection
B) Septicemia
C) Phlebitis at the infusion site
D) Superior vena cava syndrome

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.

A) Watch the site and document observations.
B) Discontinue the cannula and apply cold to the site initially for approximately 30 to 45 minutes.
C) Elevate extremity slightly.
D) Apply warm compresses after 30 to 45 minutes.

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?

A) Alteplase
B) 70% ethanol
C) Sodium bicarbonate
D) 0.1% hydrochloric acid

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?

A) 1+
B) 2+
C) 3+
D) 4+

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:

A) phlebitis.
B) infiltration.
C) fibrin sheath formation.
D) intravascular and extravascular malpositioning.

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?

A) 70% ethanol
B) Hydrochloric acid
C) Sodium bicarbonate
D) Alteplase (Activase)

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.

A) Catheter migration
B) A fibrin tail extending from the catheter tip
C) The catheter tip being pressed up against the vein wall
D) Chylothorax

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?

A) Septicemia
B) Local infection
C) Thrombophlebitis
D) Inflammatory response syndrome

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?

A) Alteplase
B) 70% ethanol
C) Sodium chloride
D) Sodium bicarbonate

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?

A) Extravasation
B) Speed shock
C) Bacterial phlebitis
D) Postinfusion phlebitis

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:

A) phlebitis.
B) a venous spasm.
C) hypersensitivity to the I.V. solution.
D) infiltration of the solution into the surrounding tissues.

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?

A) Redness along the vein
B) Cold feeling in the extremity
C) Sharp pain extending from the site of infusion
D) Increased temperature at the peripheral infusion site

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?

A) Air embolus
B) Occlusion
C) External catheter breakage
D) Displacement of the septum

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?

A) Watch the site and document observations.
B) Flush the cannula with 0.9% sodium chloride.
C) Discontinue the cannula and apply heat to site.
D) Leave the cannula in place and apply heat to the site.

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?

A) Notify the physician.
B) Start a new line proximal to the old site.
C) Discontinue the I.V. catheter at that site.
D) Apply warm moist packs to the existing I.V. site.