Chapter 15: Infusion Therapy Nursing School Test Banks

Chapter 15: Infusion Therapy

Test Bank

MULTIPLE CHOICE

1. Before the administration of intravenous fluid, it is most important for the nurse to obtain which information from the health care providers orders?

a.

Intravenous catheter size

b.

Osmolarity of the solution

c.

Vein to be used for therapy

d.

Specific type of IV fluid

ANS: D

An order for infusion therapy must contain the following to be complete: specific type of fluid, rate of administration, and drugs added to the solution. Osmolarity of the solution is not necessary because it is incorporated into the specific type of fluid. It is the nurses independent decision about the most appropriate vein to cannulate and the catheter size to use.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 212

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlError Prevention) MSC: Integrated Process: Nursing Process (Assessment)

2. Which IV order does the nurse question?

a.

Flush Groshong catheter with 10 mL normal saline every 8 hours.

b.

Infuse 20 mEq potassium chloride in 1000 mL D5W at 50 mL/hr.

c.

Infuse 500 mL normal saline over 1 hour.

d.

Infuse 0.9% normal saline at keep vein open (KVO) rate.

ANS: D

To be complete, IV orders for infusion fluids should specify the rate of infusion. This order does not specify the rate of infusion and is not considered complete.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlError Prevention) MSC: Integrated Process: Nursing Process (Analysis)

3. Which infusion device does the nurse select for the older adult client with a medical diagnosis of dehydration?

a.

Cassette pump

b.

Elastomeric balloons

c.

Volumetric controller

d.

Syringe pump

ANS: A

An older adult client who has dehydration will require a large fluid volume that is accurately measured by using a cassette pump during the infusion. Volumetric controllers count drops for administered volume and are inherently inaccurate because of variation in drop size. A syringe pump is accurate but not appropriate for a large volume. Elastomeric balloons are used to deliver intermittent medications.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlError Prevention)

MSC: Integrated Process: Nursing Process (Implementation)

4. A nursing administrator is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which action by the administrator would have the biggest impact on decreasing complications?

a.

Investigate initiating a dedicated IV team.

b.

Require inservice education for all RNs.

c.

Limit IV starts to the most experienced nurses.

d.

Perform quality control testing on skin preparation products.

ANS: A

The Centers for Disease Control and Prevention (CDC) recommends having a dedicated IV team to reduce complications, save money, and improve client satisfaction and outcomes. In-service education would always be helpful, but it would not have the same outcomes as an IV team. Limiting IV starts to the most experienced nurses does not allow newer nurses to gain this expertise. The quality of skin preparation products is only one aspect of IV insertion that could contribute to infection.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Implementation)

5. The nurse wants to find written standards for IV therapy. The nursing manager suggests that the nurse investigate publications from which resource?

a.

IV Therapy Nursing Society

b.

Infusion Nurses Society

c.

Nurses State Board of Nursing

d.

Hospitals IV solutions vendor

ANS: B

The Infusion Nurses Society publishes guidelines and standards related to IV therapy and offers a national certification examination. The State Board of Nursing publishes legal information related to nursing practice, and the solutions vendor would have written information pertaining only to specific products. The IV Therapy Nursing Society does not exist, and the other organizations listed do not provide standards and guidelines related to IV therapy.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 211

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlSafe Use of Equipment)

MSC: Integrated Process: Nursing Process (Implementation)

6. The RN assigned a new nurse to a client who was receiving chemotherapy through an intravenous extension set attached to a Huber needle. Which information about disconnecting the Huber needle is most important for the RN to provide to the new nurse?

a.

Apply topical anesthetic cream to the area after discontinuing the system.

b.

Be aware of a rebound effect when discontinuing the system.

c.

Be sure to flush the system with saline after removing the Huber needle.

d.

Place pressure over the site to prevent bleeding.

ANS: B

Huber needles are used to access implanted ports placed under the skin. Because the dense septum holds tightly to the needle, a rebound can occur when it is pulled from the septum, often resulting in needle stick injury to the nurse. Topical anesthetic cream can be used when accessing the system. Flushing is carried out when the system is accessed and once monthly. Because the implanted port is not being removed, there is no need for a pressure dressing.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

7. After discontinuing a nontunneled, percutaneous central catheter, it is most important for the nurse to record which information?

a.

Application of a sterile dressing

b.

Length of the catheter

c.

Occurrence of venospasms

d.

Type of ointment used to seal the tract

ANS: B

After removal of a catheter, measure the catheter length and compare it with the length documented on insertion. If the entire length has not been removed, the nurse should contact the physician immediately because some of the catheter may still be in the clients vein.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

8. When assessing the clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. What is the most accurate documentation of this finding?

a.

Grade 3 phlebitis at IV site

b.

Infection at IV site

c.

Thrombosed area at IV site

d.

Infiltration at IV site

ANS: A

The presence of a red streak and palpable cord indicates grade 3 phlebitis. No information in the description indicates that infection, infiltration, or thrombosis is present.

DIF: Cognitive Level: Comprehension/Understanding REF: Table 15-6, p. 233

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Assessment)

9. What information is most important to teach the client going home with a peripherally inserted central catheter (PICC) line?

a.

Avoid carrying your grandchild with the arm that has the IV.

b.

Be sure to place the arm with the IV in a sling during the day.

c.

Flush the IV line with normal saline daily.

d.

You can use the arm with the IV for most of the activities of daily living.

ANS: A

A properly placed PICC (in the antecubital fossa or the basilic vein) allows the client considerable freedom of movement. Clients can participate in most activities of daily living; however, heavy lifting can dislodge the catheter or occlude the lumen. Although it is important to keep the insertion site and tubing dry, the client can shower. The device is flushed with heparin.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

10. A client is to receive 10 days of antibiotic therapy for urosepsis. The nurse plans to insert which type of intravenous catheter?

a.

Hickman

b.

Midline

c.

Nontunneled central

d.

Short peripheral

ANS: B

Midline catheters are used for therapies lasting from 1 to 4 weeks. Short peripheral catheters can be inserted by the nurse for use with antibiotic therapy, but they can stay in only for up to 96 hours. If the length of IV therapy is longer than 6 days, a midline catheter should be chosen. Nontunneled central catheters and Hickman catheters are inserted by a physician.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 215

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

11. A client is admitted to the hospital for excessive nausea and vomiting, and a blood pressure of 90/50 mm Hg. A catheter of which gauge is most appropriate for the nurse to choose for this clients peripheral IV?

a.

24

b.

22

c.

20

d.

18

ANS: C

The nurse selects the access device most appropriate for the designated purpose. In this case, because a large amount of fluid will be needed as a result of excessive fluid loss, the appropriate needle is the 20-gauge catheter IV, because this is the most commonly used size in adults and it can be used for all fluids. The 22- and 24-gauge catheters will have a slower rate of flow, which may not be desirable with excessive fluid losses and low blood pressure. The 18-gauge catheter allows rapid flow of IV fluids. However, it requires a large vein and is more prone to irritation to the vein wall.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

12. To prevent infection when infusing an intermittent piggyback line, which intervention does the nurse implement?

a.

Backpriming the secondary container from the primary line

b.

Detaching and capping the secondary line after use

c.

Using a new secondary container with each drug infused

d.

Using sterile gloves when administering medication

ANS: A

The backpriming method allows multiple drugs to be infused through the same secondary set. This method allows the primary and secondary sets to remain connected together as an infusion system and allows the nurse to adhere to the Infusion Nurses Society (INS) standards of practice. The client is at increased risk for infection whenever the catheter is disconnected from the tubing. Sterile gloves are not necessary for IV administration of medication.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

13. The nurse finishes administering an intermittent medication through a Groshong catheter. What is the nurses next action?

a.

Clamping the catheter

b.

Flushing the line with saline

c.

Flushing with heparin

d.

Removing the access needle

ANS: B

The Groshong catheter is a type of midline catheter. After intermittent use, the catheter is to be flushed with saline. The manufacturers instructions state that the catheter should not be clamped to maintain the integrity of the catheter valve. If a heparin flush is ordered, it is given after the catheter has been flushed with saline. The access needle is used for implanted ports.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

14. The nurse is assessing several clients receiving intravenous therapy. Which client situation requires immediate intervention?

a.

Completion of an intermittent medication into a Groshong catheter

b.

Physicians order to discontinue a peripheral intravenous catheter

c.

Nonaccessed implanted port placed 1 month ago without problem

d.

Peripheral IV catheter dated 5 days ago used for once-daily antibiotics

ANS: A

A Groshong catheter is a peripherally inserted catheter that needs to be flushed with saline after intermittent use. Peripheral IV catheters should be discontinued after 4 days, so this one should be changed; however, this is not the priority. An order to discontinue the peripheral catheter requires intervention, but flushing of the Groshong catheter is more of an immediate intervention to prevent clotting of the catheter. A nonaccessed implanted port site needs to be assessed, but this is not an immediate intervention.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities)

MSC: Integrated Process: Nursing Process (Implementation)

15. In examining a peripheral IV site, the nurse observes a red streak along the length of the vein, and the vein feels hard and cordlike. What action by the nurse takes priority?

a.

Applying continuous heat

b.

Continuing to monitor site

c.

Elevating the extremity

d.

Removing the catheter

ANS: D

The clinical manifestations described are those associated with phlebitis. Phlebitis is an inflammation of the vein. Its presence in a vein being used for IV therapy may be caused by mechanical forces associated with the IV device, or by chemical factors related to the composition and osmolarity of the drug solution. The key manifestation is that symptoms are directly associated with the vein, and the catheter must be removed. Warm compresses can be applied for 20 minutes four times daily after the catheter is removed. The site needs to be monitored after the catheter is removed. The arm is not swollen. Therefore, elevation of the extremity is not a correct option.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

16. When an IV pump alarms because of pressure, what action does the nurse take first?

a.

Check for kinking of the catheter.

b.

Flush the catheter with a thrombolytic enzyme.

c.

Get a new infusion pump.

d.

Remove the IV catheter.

ANS: A

Fluid flow through the infusion system requires that pressure on the external side be greater than pressure at the catheter tip. Fluid flow can be slowed for many reasons. A common reason, and one that is easy to correct, is a kinked catheter. If this is not the cause of the pressure alarm, the nurse may have to ascertain whether a clot has formed inside the catheter lumen, or if the pump is no longer functional.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

17. The nurse is caring for four clients receiving IV therapy. Which client does the nurse assess first?

a.

Client with a newly inserted peripherally inserted central catheter (PICC) line waiting for x-ray

b.

Client with a peripheral catheter for intermittent infusions

c.

Older adult client with a nonaccessed implanted port

d.

Older adult client with normal saline infusion

ANS: D

Older adults are more prone to fluid overload and resulting congestive heart failure. Because this client is receiving continuous IV fluid, he or she is at risk for fluid overload and needs to be assessed. All other clients would need to be assessed for complications of IV catheters. However, they do not need immediate assessment.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Analysis)

18. A client who is having a tunneled central venous catheter inserted begins to report chest pain and difficulty breathing. What action does the nurse take first?

a.

Administer the PRN pain medication.

b.

Prepare to assist with chest tube insertion.

c.

Place a sterile dressing over the IV site.

d.

Place the client in the Trendelenburg position.

ANS: B

An insertion-related complication of central venous catheters is a pneumothorax. Signs and symptoms of a pneumothorax include chest pain and dyspnea. Treatment includes removing the catheter, administering oxygen, and placing a chest tube. Pain is caused by the pneumothorax, which must be taken care of with a chest tube insertion. Use of a sterile dressing and placement of the client in a Trendelenburg position are not indicated for the primary problem of a pneumothorax.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Implementation)

19. A client who has just had an IV started in the right cephalic vein tells the nurse that the wrist and the hand below the IV site feel like pins and needles. Which action by the nurse is best?

a.

Document the finding and continue to monitor the IV site.

b.

Check for the presence of a strong blood return.

c.

Discontinue the IV and restart it at another site.

d.

Elevate the extremity above the level of the heart.

ANS: C

The sensation that the client has described is related to the IV needle touching the nerve or possibly transecting the nerve. This problem can lead to loss of function and the potential for permanent disability in the distal extremity. It is considered an emergency and the IV must be discontinued. Continuing just to monitor the IV site may lead to loss of function. The presence of blood return does not indicate absence of nerve damage. Elevation of the affected extremity does not ensure that the IV catheter has moved away from the nerve.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Implementation)

20. The home care nurse is about to administer intravenous medication to the client and reads in the chart that the peripherally inserted central catheter (PICC) line in the clients left arm has been in place for 4 weeks. The IV is patent, with a good blood return. The site is clean and free from manifestations of infiltration, irritation, and infection. Which action by the nurse is most appropriate?

a.

Notify the physician.

b.

Administer the prescribed medication.

c.

Discontinue the PICC line.

d.

Switch the medication to the oral route.

ANS: B

A PICC line that is functioning well without inflammation or infection may remain in place for months or even years. Because the line shows no signs of complications, it is permissible to administer the IV antibiotic. The physician does not have to be called to have the IV route changed to an oral route.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

21. Which assessment finding for a client with a peripherally inserted central catheter (PICC) line requires immediate attention?

a.

Initial dressing over site is 3 days old.

b.

Line has been in for 4 weeks.

c.

A securement device is absent.

d.

Upper extremity swelling is noted.

ANS: D

Upper extremity swelling could indicate infiltration, and the PICC line will need to be removed. The initial dressing over the PICC site should be changed within 24 hours. This does not require immediate attention, but the swelling does. The dwell time for PICC lines can be months or even years. Securement devices are being used more often now to secure the catheter in place and prevent complications such as phlebitis and infiltration. The IV should have one, but this does not take priority over the client whose arm is swollen.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationUnexpected Response to Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

22. A nurse is changing the administration set on a clients central venous catheter. Which intervention is most important for the nurse to complete?

a.

Have the client hold his breath during the set change.

b.

Keep the slide clamp on the catheter extension open.

c.

Position the client in a high Fowlers position.

d.

Position in the client in a semi-Fowlers position.

ANS: A

An air embolus is less likely to form if the exit site is lower than the level of the heart, and if pressure in the thoracic cavity is greater when the disconnection occurs. Having the client perform the Valsalva maneuver and maintain it during disconnection and reconnection helps maintain higher intrathoracic pressure. The slide clamp on the catheter extension should be kept clamped. The client should be placed in the flat position when administration sets are changed.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

23. When assessing a clients peripheral IV site, the nurse notices edema and tenderness above the site. What action does the nurse take first?

a.

Apply cold compresses to the IV site.

b.

Elevate the extremity on a pillow.

c.

Flush the catheter.

d.

Stop the infusion of IV fluids.

ANS: D

Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of infiltration include edema and tenderness above the site. The nurse should stop the infusion and remove the catheter. Cold compresses and elevation of the extremity can be done after the catheter is discontinued to increase client comfort. Alternatively, warm compresses may be prescribed by institutional policy and may help speed circulation to the area.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationUnexpected Response to Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

24. What action does the nurse take to prevent infection in the older adult receiving IV therapy?

a.

Applying skin protectant before applying the dressing

b.

Avoiding the use of alcohol pads when removing tape

c.

Shaving the skin before attempting the venipuncture

d.

Using maximum friction to cleanse the skin

ANS: A

The skin of an older adult may be more delicate and compromised. Avoidance of a disruption in skin integrity lessens the chance of an infection occurring with an IV catheter. A barrier applied to the skin before the IV dressing is placed helps maintain skin integrity. Using alcohol pads makes it easier to remove tape and avoid skin tears. The skin should never be shaved before venipuncture because micro-abrasions may occur, and these can lead to infection. Excessive friction may damage fragile skin and compromise skin integrity.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

25. The nurse is caring for a client who is receiving an epidural infusion for pain management. Which action has the highest priority?

a.

Assessing the respiratory rate

b.

Changing the dressing over the site

c.

Using various pain management therapies

d.

Weaning the pain medication

ANS: A

Complications from an epidural infusion can be caused by the type of medication being infused, or they can be related to the catheter. When used for pain management, the client needs to be assessed for level of alertness, respiratory status, and itching. Dressings are not routinely changed because the catheter is used for only short periods. Using other pain management therapies and weaning the pain medication are important, but monitoring respiratory status has the highest priority in the nursing care of this client.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Implementation)

26. The nurse is caring for a client with a radial arterial catheter. Which assessment takes priority?

a.

Amount of pressure in fluid container

b.

Date of catheter tubing change

c.

Checking for heparin in infusion container

d.

Presence of an ulnar pulse

ANS: D

An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased perfusion to the extremity. Assessment of ulnar pulse is one way to assess circulation to the arm in which the catheter is located. The nurse would note that there is enough pressure in the fluid container to keep the system flushed, and would check to see whether the catheter tubing needs to be changed. However, these are not assessments of greatest concern. Because of heparin-induced thrombocytopenia, heparin is not used in most institutions for an arterial catheter.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

27. Five days after the start of intraperitoneal therapy, the client reports abdominal pain and feeling warm. The nurse prepares to assess the client further for evidence of which condition?

a.

Allergic reaction

b.

Bowel obstruction

c.

Catheter lumen occlusion

d.

Infection

ANS: D

Fever, abdominal pain, abdominal rigidity, and rebound tenderness may be present in the client who has peritonitis related to intraperitoneal therapy. Peritonitis is preventable by using strict aseptic technique in handling all equipment and infusion supplies. An allergic reaction would occur earlier in the course of treatment. Bowel obstruction and catheter lumen occlusion can occur but would present clinically in different ways.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationUnexpected Response to Therapies) MSC: Integrated Process: Nursing Process (Analysis)

28. Which client is the best candidate to receive hypodermoclysis for IV therapy?

a.

Client requiring 4000 mL normal saline in 24 hours

b.

Client with an extensive burn injury

c.

Client with allergy to hyaluronidase

d.

Client receiving pain management

ANS: D

Subcutaneous therapy (hypodermoclysis) involves the slow infusion of isotonic fluids into the clients subcutaneous tissue. Most often, it is used in hospices for pain management. It should not be used if fluid replacement needs exceed 3000 mL/day. To be used, the client must have sufficient areas of intact skin. Hyaluronidase is frequently used to help absorb the fluid during therapy.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 234

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapyParenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Assessment)

29. The nurse is caring for a client with an intraosseous catheter placed in the leg 20 hours ago. Which assessment is of greatest concern?

a.

Length of time catheter is in place

b.

Poor vascular access in upper extremities

c.

Affected leg cool to touch

d.

Site of intraosseous catheter placement

ANS: C

Compartment syndrome is a condition in which increased tissue perfusion in a confined anatomic space causes decreased blood flow to the area. A cool extremity can signal the possibility of this syndrome. All other distractors are important. However, the possible development of a compartment syndrome requires immediate intervention because the client could require amputation of the limb if the nurse does not pick up this perfusion problem.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 235

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Assessment)

30. A client is receiving an infusion of amiodarone (Cordarone), and the nurse notes that the clients arm has begun to blister around the IV site. This manifestation is consistent with which condition?

a.

Extravasation

b.

Infiltration

c.

Infection

d.

Phlebitis

ANS: A

Certain medications, including amiodarone, vancomycin, and ciprofloxacin, are venous irritants that can cause tissue sloughing and necrosis if the IV infiltrates. The other three complications are possible with any infusion and are not specific to amiodarone.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 211

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

31. A client is to receive a blood transfusion. Before the transfusion, what action by the nurse takes priority?

a.

Verifying the clients identity

b.

Ensuring that the blood bank has enough blood

c.

Establishing a peripheral IV site

d.

Feeding the client before starting the blood

ANS: A

Blood transfusion reactions can be devastating and can be prevented in large measure by positive client identification. This is accomplished by two professionals using two different client identifiers. Ensuring that the blood bank has enough blood would not be a normal nursing action, and transfusions can be given without regard to food and drink.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlError Prevention)

32. The nurse has just performed an IV start on a client. After the catheter has been threaded its full length in the clients vein, which action does the nurse perform next?

a.

Secure the IV with a securement device or tape.

b.

Dispose of the IV needle in the sharps container.

c.

Engage the safety mechanism of the IV catheter

d.

Note the date and time of the dressing application over the insertion site.

ANS: C

A federal law enacted in 2000 requires health care facilities to use IV catheters with an engineered safety mechanism to prevent needle sticks, which can be a source of contamination by bloodborne pathogens. This priority action would help keep the nurse safe. Securing the IV and dating/timing the dressing are also important actions, but engaging the safety mechanism comes first. After engaging the safety mechanism, safely dispose of the needle in the sharps container.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlSafe Use of Equipment)

33. A new nurse is preparing to start an IV on a client who is dehydrated and needs significant fluid volume. The new nurse selects a butterfly needle for the infusion. What action by the supervising nurse is best?

a.

Help the new nurse with the procedure as needed.

b.

Make sure the new nurse has the correct dressing.

c.

Stop the new nurse and review the procedure in private.

d.

Get the ultrasonic vein finder to help illuminate veins.

ANS: C

Winged (butterfly) needles generally are used for single doses of medications or for blood sampling. They would not be used for large volumes of fluid or kept in for any length of time. The other options do not acknowledge that the new nurses actions are incorrect and should be stopped.

DIF: Cognitive Level: Application/Applying or higher

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapyParenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

34. A nursing student asks why midline catheters need strict sterile dressing changes when short peripheral IVs do not. Which answer by the experienced nurse is most accurate?

a.

Because of the length of time they stay inserted.

b.

They really dont need strict sterile technique.

c.

Because the tip is in the right atrium of the heart.

d.

The tonicity of the fluids used promotes infection.

ANS: A

Midline catheters can stay in place for as long as 4 weeks, so dressing changes must be done with strict sterile technique to reduce the incidence of infection. The tip does not lie in the right atrium; it resides no farther than the axillary vein. These catheters are used for a wide range of fluids and medications, so tonicity would not be a factor in infection risk.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 216

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapyParenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

35. A nurse is preparing to administer two drugs at the same time to a client via a double-lumen midline catheter. Which action by the nurse is most important?

a.

Check the two drugs for compatibility.

b.

Compare the recommended infusion times.

c.

Schedule any post-infusion lab draws.

d.

Flush both lumens with saline before starting the infusion.

ANS: A

Because midline catheters dwell in the peripheral, not central, circulation, incompatible drugs should not be given together via a double-lumen midline catheter because the flow rate of the blood is not high enough to dilute the drugs before they mix. The other options are valid interventions before starting the infusion, but they do not take precedence over determining whether the drugs may be infused at the same time.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapyParenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

36. A client has just had a central venous access line inserted. What is the nurses next action?

a.

Beginning the prescribed infusion as soon as possible

b.

Confirming placement of the catheter by x-ray

c.

Having the infusion team start the IV therapy

d.

Confirming that solutions are appropriate for the central line

ANS: B

A central venous access device, once placed, needs an x-ray confirmation of proper placement before it is used. The bedside nurse would be responsible for beginning the infusion once placement has been verified. Any IV solution can be given through a central line.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlSafe Use of Equipment)

MSC: Integrated Process: Nursing Process (Implementation)

37. A new nurse is securing the connections on a new IV administration set connected to a peripherally inserted central catheter (PICC) line with tape. Which action by the precepting nurse is most appropriate?

a.

Make sure the tape being used is from a sterile IV start kit.

b.

Stop the nurse and confirm that the Luer-Lok connections are tight.

c.

Help the new nurse document the set change appropriately.

d.

Show the new nurse how to turn back the corner of the tape for easy removal.

ANS: B

PICC line administration sets must be secured using the Luer-Lok to help prevent air emboli. Using tape is not sufficient. When starting peripheral IVs, nurses must use the tape from the sterile IV start kit when possible, instead of using tape that might be dirty. Documentation is a critical function, but it does not take priority over doing a procedure correctly, nor does showing the new nurse time- and work-saving tips.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapyParenteral/Intravenous Therapies)

38. The nurse is preparing to administer an infusion of dopamine (Intropin) using a smart pump. After programming the pump and attaching the IV to the client, what action by the nurse is most important?

a.

Start the infusion as ordered.

b.

Hand-calculate the infusion rate.

c.

Ensure that the pump is plugged in.

d.

Place a time tape on the IV bag.

ANS: B

Using a smart pump does not relieve the nurse of the responsibility of ensuring that the rate is correct. Pumps can malfunction or can be programmed incorrectly, and concentrations of solution can change and differ from the pumps drug library. The nurse must hand-calculate the rate before starting the infusion, then must ensure that the pump is plugged into an electrical source. Time tapes on the sides of IV bags are no longer used to show approximate volume infused.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapyParenteral/Intravenous Therapies)

39. A student nurse is preparing to take a blood pressure (BP) on a client who has a peripheral IV line in the left arm. What instruction by the faculty member is most important?

a.

Use the arm that doesnt have the IV site in it.

b.

Dont inflate the cuff too high if you use the left arm.

c.

Make sure the IV line is secure before taking the BP.

d.

While the BP is taken, a little backflow of the IV is okay.

ANS: A

Nurses should not take blood pressure on arms that have IVs because increased pressure can cause infiltration and can cause fluid to leak from the insertion site. Because the affected arm should not be used for BP, none of the other options can be correct.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 224

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapyParenteral/Intravenous Therapies)

40. The nurse preparing to insert an IV on an older adult client notices that the clients skin is extremely fragile. Which action by the nurse is best?

a.

Use a blood pressure cuff to cause the vein to distend.

b.

Slap the skin vigorously to cause the vein to rise.

c.

Place a gauze pad under the tourniquet before tightening.

d.

Avoid the use of a tourniquet if the vein is already hard.

ANS: A

The skin of older adults is often fragile, and a tourniquet may leave an ecchymotic area after the IV insertion. One option for fragile skin is to inflate a blood pressure cuff to a reading just slightly less than the clients diastolic pressure. Tapping the skin lightly may help distend a vein, but avoid slapping vigorously. Gauze padding would not prevent bruising. Veins that are already distended may be cannulated without using a tourniquet, but they must be assessed first, and hard or cordlike veins need to be avoided.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapyParenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

41. The nurse is caring for a client admitted yesterday with an intraosseous (IO) infusion after a car crash. Which action by the nurse takes priority?

a.

Ensure that the IV flow rate has been recalculated for an IO infusion.

b.

Plan to insert another kind of IV line during the shift.

c.

Determine which IV medications can be given safely via the IO.

d.

Monitor the site and dressings routinely for hemorrhage.

ANS: B

IO infusions, although valuable in an emergency, should be left in place for only 24 hours. The nurse should plan to insert a peripheral IV sometime during the shift. IV solutions, flow rates, and medications are given the same way that they are given IV. Hemorrhage is not a complication of IO infusion.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapyParenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

MULTIPLE RESPONSE

1. The RN is working with an experienced LPN (licensed practical nurse) who has been assigned several clients receiving IV therapy. What actions guide the RN in delegating aspects of IV therapy to the LPN? (Select all that apply.)

a.

Look up and read the State Nurse Practice Act.

b.

Check facility policy regarding LPNs and IV therapy.

c.

Ask the LPN what he or she is comfortable performing.

d.

Supervise the LPN when performing IV therapy.

e.

Divide the clients up between the two of them.

ANS: A, B

The State Nurse Practice Act will have the information the RN needs, and in some states, LPNs are able to perform specific aspects of IV therapy. However, in a client care situation, it may be difficult and time-consuming to find it and read what LPNs are permitted to do, so another good solution would be for the nurse to check facility policy and follow it.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareDelegation)

2. The nurse is preparing to administer a medication IV push. What information does the nurse need to know before beginning the infusion? (Select all that apply.)

a.

Any dilution required

b.

Rate of administration

c.

Compatibility with infusions

d.

Other routes of administration

e.

Specific monitoring needed

ANS: A, B, C, E

Giving IV push medications requires specific knowledge about each drug, including dilution, rate of administration, compatibility, and monitoring. pH and osmolarity and specific infusion sites appropriate for giving the specific drug are also important to know. When giving an IV push medication, it is not necessary to know whether other routes of administration are possible.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 212

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)

3. A client has a peripherally inserted central catheter (PICC) line and the primary nurse is updating the care plan. For which common complications does the nurse assess? (Select all that apply.)

a.

Phlebitis

b.

Pneumothorax

c.

Thrombophlebitis

d.

Excessive bleeding

e.

Extravasation

ANS: A, C

Although the complication rate with PICC lines is fairly low, the most common complications are phlebitis, thrombophlebitis, and catheter-related bloodstream infection. Pneumothorax, excessive bleeding, and extravasation are not common complications.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Diagnostic Tests/Treatments/Procedures)

4. The nurse is preparing to give a client an IV push medication through an intermittent IV set (saline lock) using a needleless system. Which actions by the nurse are most appropriate? (Select all that apply.)

a.

Cleanse the access port vigorously for at least 30 seconds.

b.

Use an antimicrobial agent when cleansing the port.

c.

Clean the ridges in the Luer-Lok connection well.

d.

Rinse the antimicrobial agent off with saline.

e.

Allow the antimicrobial agent to dry before using IV.

ANS: A, B, C

Needleless systems need careful cleansing before use. Guidelines include scrubbing the connection vigorously with an antimicrobial agent for 30 seconds, and paying special attention to the ridges in the Luer-Lok device. Rinsing and drying are not necessary.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Diagnostic Tests/Treatments/Procedures)

SHORT ANSWER

1. A client is scheduled to receive 1000 mL of normal saline in 24 hours. The nurse should set the infusion pump to deliver how many milliliters per hour? _____________ mL/hr

ANS:

42

1000 mL divided by 24 hours = 41.6 mL/hr

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

2. If a client is to receive an entire 250-mL bag of saline over the next 4 hours and the drop rate of the IV tubing chamber is 15 drops/mL, at what drop rate per minute will the nurse set this IV? ____________ drops/min

ANS:

16

Drops per minute = volume drop factor total minutes

250 15 = 15.625

4 (hours) 60 (minutes/hour)

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

OTHER

1. The nurse is caring for an older adult client who has been admitted for dehydration and needs IV fluids. Which location does the nurse choose to place a peripheral IV on this client?

ANS:

B [basilic vein]

The most appropriate veins for peripheral IV therapy include the dorsal venous network and the basilic, cephalic, and median veins. However, an older client has poor skin turgor on the back of the hand, making this a poor selection. The palmar side of the wrist should be avoided because the median nerve is located there, causing increased pain and difficulty with stabilization. The cephalic vein, although large and prominent in most people, is not the best choice because the sensory branch of the median nerve intersects with it up to three times. The best choice is the basilic vein.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies-Parenteral/Intravenous Therapies)

MSC: Integrated Process: Nursing Process (Implementation)

2. The nurse is preparing to flush a PICC line. The protocol specifies using 50 units of heparin. Available is a multidose vial containing heparin, 10 units/mL. Which syringe does the nurse use to draw up and administer the heparin?

ANS:

D [the 10-mL syringe]

Always use a 10-mL syringe when flushing PICC lines because a smaller syringe creates higher pressure, which could rupture the lumen of the PICC line.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control-Safe Use of Equipment)

MSC: Integrated Process: Nursing Process (Implementation)

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