Question 1

The nurse is preparing to change the intravenous (IV)solution after the current one infuses.What action is appropriate for the nurse to take to provide for a smooth transition from the empty bag to the new one?

Accepted Answer

The nurse checks the order and prepares the next bag of IV fluid 1 hour ahead of schedule to have the solution ready for administration.This avoids disruptions in therapy.Hanging the identical IV solution can contradict the prescription.Changing the tubing with each new bag is unnecessary and wasteful.The nurse stops the infusion before air reaches the IV tubing.

Question 2

The nurse observes bleeding on the dressing of a site where the IV was discontinued.Which action should the nurse take first?

Accepted Answer

The nurse needs to hold pressure on the site since it is continuing to bleed after the IV was discontinued.Replacing the dressing will not address the cause. A warm compress causes vasodilation to increase localized blood flow.Lowering the site will increase the bleeding.

Question 3

A 5-year-old patient has intravenous (IV)fluids prescribed at 40 mL/hr,through microdrip tubing.Which rate does the nurse use to infuse the patient's IV fluid?

Accepted Answer

When the nurse uses microdrip tubing,he or she realizes that the infusion rate in drops per minute equals the hourly rate because the drip factor for this tubing is 60 gtts/mL.

Question 4

The nurse administers blood to the patient and observes that the patient has tachycardia,chills,and lower back pain.Which should the nurse implement first?

Accepted Answer

Once the nurse suspects a transfusion reaction,he or she immediately stops the infusion so the patient receives no additional blood from the current bag and quickly primes different IV tubing with saline solution.He or she uses this to replace the blood tubing but retains the blood and the tubing for the blood bank.He or she completes the vital signs and notifies the healthcare provider and the blood bank.Stopping the infusion is the priority to limit the transfusion reaction as much as possible.

Question 5

The prescription for the patient's intravenous (IV)fluid reads,"Infuse 1000 mL over 10 hours." At which rate does the nurse infuse the IV fluids using IV tubing with a drop factor of 15 gtts/mL?

Accepted Answer

1000 mL × 1 hr × 15 gtts = 25 gtts/min
10 hr 60 min 1 mL

Question 6

A patient in the emergency department needs a blood transfusion of A- blood, and none is available. Nursing care would be correct if the nurse administered blood of which type?

Accepted Answer

The nurse can administer O- because it doesn't contain any proteins or substances that the patient doesn't already have.O+ and A+ nor AB- cannot be administered because the presence of the Rh factor would cause a reaction in the patient.Th patient has antibodies to the Bantigens found in the AB- blood.

Question 7

A patient on an anticoagulant is going home and needs his peripheral intravenous (IV)line removed.Which action is essential for the nurse to take?

Accepted Answer

The patient taking an anticoagulant has a longer bleeding time; thus the nurse applies pressure to the puncture site for 5 to 10 minutes to minimize blood loss and prevent hematoma formation.The nurse removes the catheter slowly to avoid patient injury or damage to the catheter.He or she applies clean gloves because the dressing and catheter are contaminated.Checking the most recent coagulation is helpful,but,regardless of the results,extra pressure should be applied over the insertion site after removal for 5 to 10 minutes.

Question 8

The order calls for the patient to receive 500 mL of intravenous (IV)fluid over 4 hours,and the nurse uses IV tubing with a drop factor at 10 gtts/mL.Which rate should the nurse use on an electronic infusion pump for IV fluids to administer this prescription?

Accepted Answer

The electronic infusion pump administers fluid in milliliters per hour; thus the nurse programs the pump to infuse 125 mL/hr.The nurse obtains the infusion rate by dividing the total volume to be infused by the number of total hours for the infusion: 500 ÷ 4 = 125.If the nurse uses gravity to administer the fluid,he or she should use the roller clamp to limit the drops per minute to 21 gtts/min by using tubing with a drop factor of 10 gtts/mL.

Question 9

The nurse assesses the patient's intravenous (IV)site.Which clinical indicator does the nurse recognize as being most consistent with phlebitis?

Accepted Answer

The nurse scrutinizes the IV insertion site for redness along the outline of the vein through the skin.The erythema indicates inflammation of the vein.Tachycardia is consistent as a clinical indicator for infection.Cool skin is consistent with clinical indicators for infiltration.Regional edema is consistent with clinical indicators for inflammation and infection.

Question 10

The nurse is caring for a patient with a peripheral intravenous (IV)line.What should the nurse do during the IV site dressing change to prevent accidental dislodgement of the IV catheter?

Accepted Answer

To prevent accidental catheter dislodgement,the nurse stabilizes the IV catheter with the nondominant hand until the agency-approved covering is in place during the IV dressing change.The nurse avoids applying traction or bending the catheter to maintain infection control and the integrity of the catheter.The nurse places a folded 2 × 2-inch gauze pad under the hub to prevent excessive skin pressure from the hub.He or she wears clean gloves to remove the old dressing to prevent self-contamination.The insertion site is cleansed using a circular motion from the center to the exterior of the site to prevent recontamination.

Question 11

The nurse is preparing to initiate a blood transfusion.Which step of the procedure should the nurse implement first?

Accepted Answer

The nurse initiates infusion of the blood very slowly at 2 mL/min to prevent the infusion of a large volume bolus of potentially incompatible blood.Most transfusion reactions occur during the first 15 minutes of the infusion; thus the nurse continues the slow rate for 15 minutes while closely monitoring the patient for a transfusion reaction.The nurse needs to infuse blood products through a Y-tubing administration set.The nurse evaluates the patient's vital signs within 5 minutes of starting the infusion for 15 minutes and then every 15 minutes or according to agency policy.The nurse avoids shaking blood products because violent movement damages erythrocytes and increases their hemolysis.

Question 12

2. _________ _________is a specialized form of nutritional support in which nutrients are given intravenously (IV)through a CVAD by an infusion pump to patients with significant gastrointestinal (GI)dysfunction.

Accepted Answer

The answer of 2. _________ _________is a specialized form of...

Question 13

The nurse is trying to get an intravenous (IV)line to last several days.What responsibility does the nurse have related to the assessment and maintenance of a peripheral IV site?

Accepted Answer

The nurse inspects the insertion site regularly for early detection of inflammation,infection,phlebitis,and leakage to fulfill the duty the nurse owes to the patient for preventing complications.Elevating the patient's arm is unnecessary.Changing the site daily increases patient risk for infection and trauma.Padding the site obstructs direct observation of the site and prevents early detection of complications; the best method of protecting the IV site is patient education and continuously observing site.

Question 14

The nurse is administering parenteral nutrition via a central venous access device.Which outcome would best substantiate the nurse's assessment that this therapy is effective?

Accepted Answer

The patient should gain between 1 and 3 pounds per week on parenteral nutrition.Four and a half pounds is too much of a weight gain in 1 week.The blood glucose level is too high.The patient's statement is subjective datum and is less accurate than measurable data.

Question 15

1. A ________ infusion occurs when the flow rate is set at an ordered rate and given over a 24-hour period.

Accepted Answer

The answer of 1. A ________ infusion occurs when the...

Quiz 27: Intravenous and Vascular Access Therapy

The nurse is preparing to change the intravenous (IV) solution after the current one infuses.What action is appropriate for the nurse to take to provide for a smooth transition from the empty bag to the new one?

The nurse observes bleeding on the dressing of a site where the IV was discontinued.Which action should the nurse take first?

A 5-year-old patient has intravenous (IV) fluids prescribed at 40 mL/hr,through microdrip tubing.Which rate does the nurse use to infuse the patient's IV fluid?

The nurse administers blood to the patient and observes that the patient has tachycardia,chills,and lower back pain.Which should the nurse implement first?

The prescription for the patient's intravenous (IV) fluid reads,"Infuse 1000 mL over 10 hours." At which rate does the nurse infuse the IV fluids using IV tubing with a drop factor of 15 gtts/mL?

A patient in the emergency department needs a blood transfusion of A- blood, and none is available. Nursing care would be correct if the nurse administered blood of which type?

A patient on an anticoagulant is going home and needs his peripheral intravenous (IV) line removed.Which action is essential for the nurse to take?

The order calls for the patient to receive 500 mL of intravenous (IV) fluid over 4 hours,and the nurse uses IV tubing with a drop factor at 10 gtts/mL.Which rate should the nurse use on an electronic infusion pump for IV fluids to administer this prescription?

The nurse assesses the patient's intravenous (IV) site.Which clinical indicator does the nurse recognize as being most consistent with phlebitis?

The nurse is caring for a patient with a peripheral intravenous (IV) line.What should the nurse do during the IV site dressing change to prevent accidental dislodgement of the IV catheter?

The nurse is preparing to initiate a blood transfusion.Which step of the procedure should the nurse implement first?

2. _ _is a specialized form of nutritional support in which nutrients are given intravenously (IV)through a CVAD by an infusion pump to patients with significant gastrointestinal (GI)dysfunction.

The nurse is trying to get an intravenous (IV) line to last several days.What responsibility does the nurse have related to the assessment and maintenance of a peripheral IV site?

The nurse is administering parenteral nutrition via a central venous access device.Which outcome would best substantiate the nurse's assessment that this therapy is effective?

1. A ________ infusion occurs when the flow rate is set at an ordered rate and given over a 24-hour period.