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?

Accepted Answer

The patient is exhibiting signs of fluid overload, including crackles in the lungs, distended neck veins, edema, and weight gain. This indicates an excess fluid volume, which is the most appropriate nursing diagnosis for this situation.

Question 2

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

Accepted Answer

Positioning the patient on the left side with the head down is not appropriate for changing a central line dressing and could increase the risk of air embolism.

Question 3

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

Accepted Answer

Assessing lung sounds for crackles is a priority as it can quickly identify pulmonary edema, a common and potentially serious complication of fluid overload, requiring immediate intervention.

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?

Accepted Answer

The appearance of a white precipitate in IV tubing can indicate a potential incompatibility or reaction between two medications. The first action should be to stop the infusion to prevent any further administration of the potentially harmful mixture. After stopping the infusion, the nurse can then evaluate the situation by consulting with the pharmacy or notifying the physician if necessary. Sending the tubing to the laboratory for analysis would not be a priority action in this scenario.

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?

Accepted Answer

Repositioning the extremity can help if the catheter is against a vein wall or if there is a positional occlusion.

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?

Accepted Answer

As soon as blood begins to spurt from the site, the catheter must be removed and pressure applied to the site immediately to minimize bleeding and prevent hematoma formation. If the catheter is completed first, it may cause further damage to the vein or tissue, increasing the risk of infection and delaying treatment. Option A is incorrect because finishing threading the catheter before addressing the bleeding is not the priority. Option B is incorrect because inserting another catheter in the same site is contraindicated due to the bleeding and possible tissue damage. Option D is incorrect because there is no need to call for help in this situation.

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?

Accepted Answer

The symptoms described, including taut and cool skin, swelling with dependent positioning, suggest that the IV may have infiltrated. Infiltration occurs when the IV catheter or needle punctures the vein and the IV fluid leaks into the surrounding tissue. This can cause swelling, coolness, tautness, and pain. Infection may present with redness, warmth, and tenderness around the site, while venous spasm typically causes pain and difficulty with flushing the IV. Embolism is a more serious complication that may cause sudden pain, discoloration, and/or loss of pulses in the affected limb.

Question 8

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

Accepted Answer

The nurse should remove the dressing from the IV site to observe the insertion site and assess for any signs of infection, infiltration, or phlebitis. The wet tape may have caused the site to become loose, allowing for leakage. The nurse may need to resecure the site with a new dressing or adjust the catheter's position. Calling the physician or increasing the IV drip rate would not be appropriate until the nurse has assessed the site and taken appropriate action. Reducing the IV flow rate may be necessary, but it should not be the first action taken without assessing the site.

Question 9

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

Accepted Answer

The angiocatheter site being red and tender may indicate a possible infection, and the first action should be to remove the catheter to prevent further complications.

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?

Accepted Answer

The evidence that a chlorhexidine-containing antiseptic regimen reduces catheter-related infection by 49% best supports the decision to bundle the central line insertion and dressing kits with 2% chlorhexidine gluconate for site preparation and cleansing.

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?

Accepted Answer

Tapering the TPN rate and introducing regular feedings slowly is the most appropriate option as it allows for a gradual transition from TPN to oral feeding, minimizing the risk of refeeding syndrome and other complications. Starting tube feedings or placing the patient on clear liquids may not be appropriate at this stage, while a sodium-restricted diet with high-protein snacks is not relevant to the situation.

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?

Accepted Answer

Checking for kinking of the tubing or a closed clamp should be the first action taken to address the occlusion alarm. This could be causing the interruption in the flow of the IV solution. If the problem persists, further actions such as notifying the physician or flushing the line may be necessary. Decreasing the rate and flushing with heparin solution would not be appropriate in this situation as the issue is likely related to a mechanical obstruction rather than a clot in the line.

Question 13

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

Accepted Answer

The hand is typically used first for IV catheter insertion in a newly admitted patient to preserve other sites for future use and to allow for easier access if complications arise.

Question 14

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

Accepted Answer

The answer of What type of solution is used to...

Question 15

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

Accepted Answer

The SASH technique is used when the medication is not compatible with heparin to prevent any potential interaction between the medication and heparin.

Question 16

Which technique best dilates a vein for venipuncture?

Accepted Answer

Applying a tourniquet for up to 3 minutes helps dilate the vein and make it easier to locate for venipuncture. Elevating the extremity and applying a cool compress may help with discomfort and reduce swelling, but they do not directly dilate the vein. Applying an alcohol swab for 60 seconds is important for sterilization, but does not help dilate the vein.

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?

Accepted Answer

A PICC (peripherally inserted central catheter) line is an intravenous device that is inserted into a peripheral arm vein and threaded through to the large veins near the heart. It allows for medication to be delivered directly into the central circulation and can be used for an extended period of time. It is a commonly used device in oncology clinics for chemotherapy and other drug infusions. Choice A is incorrect as a jugular vein is not typically used for PICC line placement. Choice B is incorrect as a PICC line uses a larger catheter than a regular IV. Choice C is also incorrect as it does not accurately describe what a PICC line is.

Question 18

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

Accepted Answer

Flexing the extremity above the insertion site can slow the flow rate of a gravity solution by increasing resistance to flow.

Question 19

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

Accepted Answer

A hypertonic intravenous solution has a higher solute concentration than the surrounding interstitial fluid. As a result, water is drawn out of the interstitial space and into the venous circulation to dilute the hypertonic solution, causing fluid shift from the interstitial space into the venous circulation.

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?

Accepted Answer

TPN solutions contain high amounts of glucose, which can cause hyperglycemia. Regular monitoring of blood glucose levels is necessary to ensure that glucose levels do not get too high. The other options are either incorrect or do not provide sufficient explanation.

Quiz 7: Nursing Care of Patients Receiving Intravenous Therapy