Chapter 28: Intravenous and Vascular Access Therapy Nursing School Test Banks

MULTIPLE CHOICE

1. The nurse is caring for a patient receiving antineoplastic medications intravenously. The nurse discovers that the intravenous site is red, edematous, and painful. The nurse knows that antineoplastic medications are vesicant medications and documents that the patient has experienced which of the following events?

a.

Occlusion

b.

Extravasation

c.

Phlebitis

d.

Thrombophlebitis

ANS: B

When a vesicant medication infiltrates the tissue, this is called an extravasation. Occlusion refers to a thrombus or fibrin sheath that impedes the flow of IV fluids. Phlebitis occurs with redness surrounding the vein, and extravasation leads to trauma within the vein

DIF: Cognitive Level: Application REF: Text reference: p. 735

OBJ: Define the key terms used in the skills of intravenous therapy.

TOP: Assessment of IV Site KEY: Nursing Process Step: Diagnosis

MSC: NCLEX: Physiological Integrity

2. Established standards for routine replacement of peripheral IV catheters and intravenous administration sets have recommended a maximum of _____ hours to reduce IV fluid contamination and prevent catheter site complications.

a.

24

b.

48

c.

72

d.

96

ANS: D

Established standards for routine replacement of peripheral IV catheters and intravenous administration sets have recommended a maximum of 96 hours to reduce IV fluid contamination and prevent catheter site complications.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 695 |Text reference: p. 716

OBJ: Discuss complications of IV therapy.

TOP: Replacement of IV Catheters and Administration Sets

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

3. While assessing the patient, the nurse recognizes that special caution should be taken with the IV infusion because of fluid volume excess when the nurse notes the presence of which condition?

a.

Poor skin turgor

b.

Crackles in the lungs

c.

Decreased blood pressure

d.

Dry skin and mucous membranes

ANS: B

Auscultation of crackles or rhonchi in the lungs may signal fluid buildup in the lungs caused by fluid volume excess. Poor skin turgor is common with fluid volume deficit. The pinched skin stays elevated for several seconds (tenting). This may be an indication of the need for IV therapy. Decreased blood pressure may indicate fluid volume deficit caused by a decrease in stroke volume. This may indicate the need for IV therapy. Dry skin and mucous membranes may indicate dehydration.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 698 |Text reference: p. 707

OBJ: Discuss complications of IV therapy.

TOP: Fluid Volume Excess KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

4. The nurse needs to specifically prevent air emboli that may result from IV therapy. What should the nurse make sure to do to prevent air emboli?

a.

Use a needleless system.

b.

Prime the tubing completely.

c.

Check for medication compatibility.

d.

Select a larger-gauge needle or catheter.

ANS: B

Prime the infusion tubing by filling it with IV solution. Be certain that the tubing is clear of air and air bubbles. Large air bubbles can act as emboli. A needleless system does not specifically prevent the introduction of air emboli. Medication incompatibility may lead to crystallization of the medication and may cause emboli to form from precipitate. It will not lead, however, to air embolism. Catheter size does not contribute to emboli formation.

DIF: Cognitive Level: Application REF: Text reference: p. 700

OBJ: Discuss complications of IV therapy. TOP: Air Embolism

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

5. Which of the following steps is necessary when a patient is prepared for IV insertion?

a.

Shaving the hair from the site

b.

Selecting a proximal site in an extremity

c.

Applying a tourniquet 4 to 6 inches above the selected site

d.

Vigorously taping and massaging the selected vein

ANS: C

Apply a flat tourniquet around the arm, above the antecubital fossa or 4 to 6 inches (10 to 15 cm) above the proposed insertion site. Do not shave the area. Shaving may cause microabrasions and may predispose to infection. Use the most distal site in the nondominant arm, if possible. Vigorous friction and multiple taping of the veins, especially in older adults, may cause hematoma and/or venous constriction.

DIF: Cognitive Level: Application REF: Text reference: p. 701

OBJ: Explain how to prepare the patient and the family for IV therapy.

TOP: Applying a Tourniquet KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

6. What should be the next action by the nurse, once an over-the-needle catheter (ONC) has been inserted through the skin and into the vein?

a.

Loosen the stylet for removal

b.

Check for blood return in the flashback chamber

c.

Stabilize the catheter and release the tourniquet

d.

Advance the catheter until the hub rests at the insertion site

ANS: B

Observe for blood return through the flashback chamber of the catheter or the tubing of the winged cannula, indicating that the bevel of the needle has entered the vein. Lower the needle until almost flush with the skin. Advance the catheter another to inch into the vein, and then loosen the stylet site on the ONC. Only after the catheter is advanced and is in its final position is the catheter stabilized with one hand while the tourniquet is released. Only after the blood and the needle are observed to advance another to inch into the vein is the stylet loosened. At that point, continue to hold the skin taut, and advance the catheter into the vein until the hub rests at the venipuncture site.

DIF: Cognitive Level: Application REF: Text reference: p. 703

OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV.

TOP: Inserting the Over-the-Needle Catheter

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

7. What should the nurse do once she recognizes that the patient has phlebitis at his IV site?

a.

Reduce the IV flow rate.

b.

Elevate the affected extremity.

c.

Place a moist warm compress over the site.

d.

Adjust the additive in the current IV.

ANS: C

Phlebitis is indicated by pain, increased skin temperature, and erythema along the path of the vein. Stop the infusion and discontinue the IV. Start a new IV if continued therapy is necessary. Place a moist warm compress over the area of phlebitis. Document the degree of phlebitis and nursing interventions per agency policy and procedure. The extremity is elevated for an infiltration to reduce edema.

DIF: Cognitive Level: Application REF: Text reference: p. 707

OBJ: Discuss complications of IV therapy. TOP: Phlebitis

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

8. What should the nurse do upon noting bleeding around a dressing at an IV insertion site?

a.

Discontinue the IV.

b.

Assess the insertion site.

c.

Leave the dressing intact, but reinforce it.

d.

Elevate and apply warm compresses to the extremity.

ANS: B

When blood appears on the dressing, verify that the system is intact, and change the dressing. The IV should be discontinued in the event of infiltration or phlebitis. If bleeding occurs around the venipuncture site and the catheter is within the vein, gauze dressing may be applied over the site. Be aware that if gauze dressing is used, it must be removed to accurately assess the insertion site. Elevation is used in cases of infiltration to reduce edema. Warm compresses are used in cases of phlebitis.

DIF: Cognitive Level: Application REF: Text reference: p. 707

OBJ: Discuss complications of IV therapy.

TOP: Bleeding at Venipuncture Site KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

9. Which patient would a nurse anticipate would be a candidate for a peripherally inserted central catheter (PICC)?

a.

An older adult who is having cataracts removed

b.

A perinatal patient who is having prolonged labor

c.

A neonate requiring blood therapy

d.

An adolescent who is having surgery for reduction of a fracture

ANS: C

When a child is critically ill or when long-term IV access is anticipated, a PICC catheter, a Broviac catheter, or an implanted port may be used to access a larger vein. PICCs can be used to infuse IV fluids, parenteral nutrition, blood and blood products, and medications such as antibiotics. Gerontological veins are very fragile, with less subcutaneous support tissue and with thinning of the skin. In older patients, use the smallest gauge possible. For example, a 22-gauge needle is adequate for fluid and medication therapy. PICC lines are not inserted routinely. PICCs are used when long-term IV is needed.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 695 |Text reference: pp. 724-725

OBJ: Explain how to prepare the patient and the family for IV therapy.

TOP: Pediatric Considerations KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

10. The nurse is caring for a patient receiving intravenous therapy. The nurse should report which of the following to the primary care provider?

a.

Completion of each liter of fluid

b.

Initiation of IV fluids

c.

Small infiltration

d.

Extravasation

ANS: D

If a patient suffers an extravasation, the primary care provider should be notified as soon as possible because complications of some vesicants can be reduced by injection of specific medications, whereas others require rapid medical intervention. It is not necessary to report when you routinely initiate or complete IV therapy. Primary care providers do not need to be notified of a small infiltrate, but it should be documented in the patients medical record, and your facility may require completion of an event reporting form.

DIF: Cognitive Level: Application REF: Text reference: p. 707 |Text reference: p. 735

OBJ: Demonstrate appropriate documentation and reporting of intravenous therapy.

TOP: Assessment of IV Therapy Access Devices

KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

11. The patient has an IV ordered to infuse at 1000 mL over 10 hours. The infusion set has a calibration of 15 gtt/mL. At which rate does the nurse regulate the infusion?

a.

20 gtt/min

b.

25 gtt/min

c.

30 gtt/min

d.

32 gtt/min

ANS: B

Select one of the following formulas to calculate drop rate based on drops per minute: mL/hr/60 min = mL/min followed by Drop factor mL/min = Drops/min, or mL/hr Drop factor/60 min = Drops/min.

DIF: Cognitive Level: Analysis REF: Text reference: pp. 710-711

OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV.

TOP: IV Rate Calculation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

12. The order is for the patient to receive 500 mL over 4 hours. The nurse has an electronic infusion device (EID) in place that provides for the regulation of hourly infusion. The IV tubing available is 10 gtt/mL. What is the setting for the infusion device?

a.

125 mL/hr

b.

500 mL/hr

c.

21 gtt/min

d.

32 gtt/min

ANS: A

For use of EID for infusion, turn on the power button, select the required drops per minute or volume per hour, close the door to the control chamber, and press the start button. In this case, 500 mL/4 hr = 125 mL/hr.

DIF: Cognitive Level: Analysis REF: Text reference: pp. 710-711

OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV.

TOP: IV Rate Regulation via EID KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

13. A pediatric patient has an IV with a microdrip. The order is for 40 mL/hr to infuse. At what rate does the nurse set the microdrip?

a.

10 gtt/min

b.

20 gtt/min

c.

40 gtt/min

d.

80 gtt/min

ANS: C

Select one of the following formulas to calculate drop rate based on drops per minute: mL/hr/60 min = mL/min followed by Drop factor mL/min = drops/min, or mL/hr Drop factor/60 min = drops/min. In this case, 40 mL/hr 60 gtt/mL = 240 gtt/hr 1 hr/60 min = 40 gtt/min. When microdrip is used, mL/hr always equals gtt/min.

DIF: Cognitive Level: Analysis REF: Text reference: p. 711

OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV.

TOP: IV Rate Regulation via Microdrip KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

14. While assessing the patients IV infusion, the nurse notes that it is infusing more slowly than it should be. What should the nurse do first?

a.

Discontinue the IV.

b.

Increase the rate of infusion.

c.

Observe for fluid overload.

d.

Check the position of the IV fluid and extremity.

ANS: D

Check the patient for positional changes that might affect infusion rate, height of the IV container, and tubing obstruction. Check the condition of the site. The most likely cause of a slow-running IV is positioning. An infiltrated or clotted IV line probably will not be running at all. Discontinue the IV if it is determined that it is infiltrated or clotted off. Position will affect flow even if rate is increased. Fluid overload is not associated with slowing of the infusion rate. Often it occurs when an IV is running too quickly.

DIF: Cognitive Level: Application REF: Text reference: p. 712

OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV.

TOP: Slow-Running IV KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

15. The nurse caring for a patient receiving IV fluids knows that the current recommendation for changing the tubing on a continuously running IV is:

a.

at least every 48 hours.

b.

every 24 hours.

c.

no more often than every 96 hours.

d.

with each IV solution bag change.

ANS: C

Intravenous tubing administration sets remain sterile for 96 hours. Thus, the INS recommends changing tubing no more frequently than every 96 hours. When possible, schedule tubing changes when it is time to hang a new IV container.

DIF: Cognitive Level: Application REF: Text reference: p. 695 |Text reference: p. 716

OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV.

TOP: IV Tubing Change for Continuous Infusions

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

16. The nurse is caring for a patient diagnosed with pneumonia who receives IV antibiotics every 8 hours. How often should the nurse change the primary intermittent IV sets?

a.

No more often than every 72 hours

b.

At least every 72 hours

c.

With each IV bag change

d.

Every 24 hours

ANS: D

You should change primary intermittent sets every 24 hours because the IV system becomes interrupted, which increases the risk for contamination.

DIF: Cognitive Level: Application REF: Text reference: p. 716

OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV.

TOP: IV Tubing Change for Intermittent Infusions

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

17. What is an appropriate technique for the nurse to implement when changing the dressing at a peripheral IV site?

a.

Wear sterile gloves to remove the old dressing.

b.

Keep one finger over the IV catheter until the tape is replaced.

c.

Cleanse with an antiseptic solution in a circular manner toward the site.

d.

Tape the connection between the IV catheter port and the tubing.

ANS: B

Keep one finger over the catheter at all times until the tape or dressing secures placement. If the patient is restless or uncooperative, it is helpful to have another staff member assist with the procedure. Perform hand hygiene. Apply disposable gloves. Apply the final swab in a circular pattern, moving outward from the insertion site. Do not tape over the connection of the access tubing or port to the IV catheter.

DIF: Cognitive Level: Application REF: Text reference: p. 721

OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV.

TOP: IV Dressing Change KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

18. What should the nurse do when discontinuing a peripheral IV?

a.

Withdraw the catheter quickly.

b.

Keep the hub perpendicular to the skin.

c.

Apply pressure to the site for 1 minute.

d.

Inspect the catheter for intactness after removal.

ANS: D

Inspect the catheter for intactness after removal, noting tip integrity and length. Place clean sterile gauze above the site, and withdraw the catheter, using a slow, steady motion. Keep the hub parallel to the skin. Do not raise or lift the catheter before it is completely out of the vein, to avoid trauma or hematoma formation. Apply pressure to the site for 2 to 3 minutes, using a dry, sterile gauze pad. Secure with tape. Note: Apply pressure for 5 to 10 minutes if the patient is taking anticoagulants.

DIF: Cognitive Level: Application REF: Text reference: p. 724

OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV.

TOP: Discontinuing a Peripheral IV KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

19. The patient is expected to require intravenous therapy for several years as treatment for a chronic disease process. Which of the following would be the best choice for venous access in this patient?

a.

Peripherally inserted central catheter (PICC)

b.

Nontunneled percutaneous central venous catheter

c.

Subcutaneous implanted port

d.

Peripheral IV

ANS: C

Implanted infusion ports are used for long-term and complex IV therapy. When not in use, no external catheter is present, and port manufacturers recommend that the port be heparinized every 4 weeks to maintain patency. No other care is required for an unused port. PICCs provide alternative IV access when the patient requires intermediate-length venous access (>7 days to several months). These catheters are used for shorter placements (e.g., 5 to 10 days). Use of peripheral IV therapy increases the risk for patients to develop infection, vein sclerosis, phlebitis, and infiltration.

DIF: Cognitive Level: Synthesis REF: Text reference: pp. 724-725

OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance. TOP: Subcutaneous Implanted Ports

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

20. The nurse is assisting the physician during the insertion of a central line into the subclavian vein. How should the nurse cleanse the area?

a.

With chlorhexidine in a back and forth scrubbing motion

b.

With chlorhexidine followed by alcohol in a back and forth scrubbing motion

c.

With alcohol in a circular motion for 5 minutes

d.

With antimicrobial solution that must be dabbed dry with a sterile towel

ANS: A

Antiseptics such as chlorhexidine remove resident and transient bacteria. Alcohol should not be applied after the application of iodophor solution. Chlorhexidine is scrubbed in a back and forth motion for 30 seconds. Allow the antimicrobial solution to air-dry completely. This ensures maximum antimicrobial effect.

DIF: Cognitive Level: Application REF: Text reference: p. 728

OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance. TOP: Inserting a Central Venous Access Device

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

21. The nurse is preparing to draw blood from a central venous access device for blood cultures. Which of the following steps is part of that process?

a.

Apply sterile gloves.

b.

Flush the port with 5 to 10 mL of 0.9% sodium chloride.

c.

Slowly aspirate 5 mL of blood and discard the syringe.

d.

Use the distal lumen to draw blood.

ANS: D

Use the distal (red or brown) lumen to draw blood if the device has more than one lumen. The distal (red or brown) lumen typically is the largest-gauge lumen. Apply clean gloves to prevent transfer of body fluids. Do not flush before drawing blood for blood cultures. If blood cultures have been ordered, do not discard any blood. Use the initial specimen for blood cultures.

DIF: Cognitive Level: Application REF: Text reference: p. 730

OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance. TOP: Blood Sampling

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

22. What should the nurse do to decrease the potential for infection related to IV therapy?

a.

Use the clean technique for dressing changes.

b.

Change the IV tubing every 12 hours.

c.

Palpate the insertion site daily through the intact dressing.

d.

After cleansing the skin, dab it dry with a sterile gauze pad.

ANS: C

Palpate the catheter insertion site for tenderness daily through the intact dressing. Perform hand hygiene before and after palpating, inserting, replacing, or dressing any intravascular device. Maintain use of sterile dressings. Replace IV tubing no more frequently than at 72-hour intervals unless clinically indicated. Allow the site to air-dry before proceeding with the procedure.

DIF: Cognitive Level: Application REF: Text reference: p. 696

OBJ: Explain techniques for preventing transmission of infection for a patient receiving IV therapy.

TOP: Standards to Decrease Intravascular Infection Related to IV Therapy

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

23. The nurse is caring for a patient with a continuous intravenous infusion of 0.9% normal saline with 40 mEq of potassium chloride added to each liter. During a routine hourly check of the infusion, the nurse discovers that 4 hours of fluid has infused in the past 1 hour. The nurses first action should be to:

a.

notify the primary care provider.

b.

assess the patient.

c.

reduce the infusion rate.

d.

notify the charge nurse.

ANS: C

If the intravenous fluid is infusing 4 times faster than ordered, the first intervention should be to reduce the rate. Notification of the primary care provider and the charge nurse would occur after the flow rate is reduced and an assessment of the patient is performed. Although assessing the patient is vitally important, you do not want to allow the fluid to continue infusing at a rapid rate while you are performing the assessment.

DIF: Cognitive Level: Analysis REF: Text reference: p. 712

OBJ: Identify interventions required to prevent complications associated with

TOP: IV Administration Rates KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

24. The nurse is caring for a patient who has experienced hypovolemia secondary to acute vomiting and diarrhea. The nurse anticipates what type of intravenous fluid to be ordered by the health care provider?

a.

Hypotonic or isotonic solutions

b.

Hypertonic or isotonic solutions

c.

Hypertonic solutions only

d.

Whole blood

ANS: A

Hypotonic solutions are administered for cellular dehydration, whereas isotonic solutions replace intravascular fluid, so both of these might be appropriate for this patient. Hypertonic solutions pull fluid from extravascular spaces and would not be appropriate for this patient. Whole blood is not indicated because there is no evidence of blood loss.

DIF: Cognitive Level: Analysis REF: Text reference: p. 694

OBJ: Identify common types of intravenous fluids. TOP: Different IV Fluids

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

25. Which of the following patients would the nurse anticipate requiring the placement of a central venous catheter?

a.

A patient in same-day surgery who might require blood transfusions

b.

A patient in the intensive care unit requiring multiple simultaneous intravenous medications

c.

A patient in the cardiac care unit diagnosed with possible myocardial infarction

d.

A patient on the surgical unit recovering from hernia repair

ANS: B

The most likely candidate for a central venous catheter is the patient in intensive care requiring the administration of multiple medications. The central venous catheter will simplify the administration of multiple medications to this critically ill patient. Because same-day surgery patients are expected to go home at the end of the day, it would be unlikely this patient would need a central catheter. A patient diagnosed with myocardial infarction would be unlikely to need a central line unless his condition deteriorated. A patient post hernia repair would be unlikely to require a central venous line unless complications arose, which is not indicated in this scenario.

DIF: Cognitive Level: Application REF: Text reference: p. 725

OBJ: Identify indications and contraindications for intravenous therapy and central venous lines.

TOP: Tunneled Central Venous Catheters

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

26. The nurse assigns nursing assistive personnel (NAP) to care for several patients with continuous IV infusions. Which of the following can NAP assist with?

a.

Changing empty IV solution containers

b.

Confirming the correct IV drip rate

c.

Assessing the patient for response to IV therapy

d.

Informing the nurse if they notice anything abnormal

ANS: D

If UAP notice anything they consider abnormal, they should notify the nurse. It is the nurses responsibility to inform the UAP of specific things to look for. Changing empty IV solution containers cannot be delegated to UAP because the procedure requires knowledge of sterile technique. Confirming the correct IV drip rate is the nurses responsibility. Assessment is not the responsibility of UAP; it is the responsibility of the nurse.

DIF: Cognitive Level: Application REF: Text reference: p. 697

OBJ: Recognize when it is appropriate to delegate aspects of intravenous therapy to unlicensed assistive personnel. TOP: Intravenous Devices

KEY: Nursing Process Step: Planning MSC: NCLEX: Safe and Effective Care Environment

MULTIPLE RESPONSE

1. The patient is on daily weights and is receiving intravenous therapy. The nurse notices that the patient has gained 2 kg since the previous morning. What else would the nurse expect to observe? (Select all that apply.)

a.

Dry skin and mucous membranes

b.

Distended neck veins

c.

Tenting of the skin

d.

Crackles or rhonchi in the lungs

ANS: B, D

A change in body weight of 1 kg corresponds to 1 L of fluid retention or loss. Dry skin and mucous membranes suggest fluid volume deficit (FVD). Distended neck veins suggest fluid volume excess (FVE). Poor skin turgor is seen when after pinching, the skin fails to return to normal position within 3 seconds. With FVD, the pinched skin stays elevated for several seconds. This is called tenting. Auscultation of crackles or rhonchi in the lungs may signal fluid buildup in the lungs caused by FVE.

DIF: Cognitive Level: Analysis REF: Text reference: p. 698 |Text reference: p. 707

OBJ: Discuss complications of IV therapy.

TOP: Fluid Volume Excess KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. What should the nurse do upon noting that the patients IV site is pale, cool, and edematous? (Select all that apply.)

a.

Stop the infusion.

b.

Elevate the extremity.

c.

Start a new IV.

d.

Flush the IV site.

ANS: A, B, C

Infiltration is indicated by swelling and possible pitting edema, pallor, coolness, pain at the insertion site, and a possible decrease in flow rate. The nurse should stop the infusion and should discontinue the IV, elevate the affected extremity, start a new IV if continued therapy is necessary, and document the degree of infiltration and nursing intervention. Flushing the IV site is not recommended.

DIF: Cognitive Level: Application REF: Text reference: p. 707

OBJ: Discuss complications of IV therapy. TOP: Infiltration

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

3. The nurse is preparing to start an IV on a 92-year-old patient. The nurse realizes that she may need to take which of the following actions? (Select all that apply.)

a.

Avoid using veins in the hand.

b.

Avoid using veins in the dominant arm.

c.

Use the largest-gauge catheter possible for maximum flow.

d.

Avoid using a tourniquet.

ANS: A, B, D

In older patients, use the smallest gauge possible. For example, a 22-gauge needle is adequate for fluid and medication therapy; use a 24-gauge in frail, older adults. Smaller-gauge catheters are less traumatizing to the vein but still allow blood flow to provide increased hemodilution of IV fluids or medications. If possible, avoid the back of the older adults hand or the dominant arm for venipuncture because they interfere with the older adults independence. Minimize pressure from tourniquets, or avoid them if possible. Apply a blood pressure cuff in place of a tourniquet.

DIF: Cognitive Level: Application REF: Text reference: p. 701 |Text reference: p. 708

OBJ: Explain how to prepare the patient and the family for IV therapy.

TOP: Starting IVs in Older Patients KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4. For which patients are electronic infusion devices (EIDs) used? (Select all that apply.)

a.

Those who require low hourly rates

b.

Those who are at risk for volume overload

c.

Those who have impaired renal clearance

d.

Those who are receiving fluids that require a specific hourly volume

ANS: A, B, C, D

Infusion pumps are necessary for patients requiring low hourly rates, at risk for volume overload, with impaired renal clearance, or receiving medications or fluids that require a specific hourly volume.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 709

OBJ: Explain how to prepare the patient and the family for IV therapy.

TOP: Electronic Infusion Device (EID) KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

5. Central venous access devices (CVADs) can be used in the home, in the hospital, and in long-term care facilities for patients who require which of the following? (Select all that apply.)

a.

Supplemental nutrition

b.

Blood and blood products

c.

Hemodynamic monitoring

d.

Blood sampling

ANS: A, B, C, D

CVADs can be used in the home, in the hospital, and in long-term care facilities for patients who require supplemental nutrition, blood and blood products, continuous fluids, medications, hemodynamic monitoring, and blood sampling.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 716 |Text reference: pp. 724-725

OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance. TOP: Central Venous Access Devices (CVADs)

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

6. Which of the following are CVADs? (Select all that apply.)

a.

Implanted subcutaneous ports

b.

Peripherally inserted central catheter (PICC) lines

c.

Saline locks

d.

Heparin locks

ANS: A, B

Four types of CVADs are available: nontunneled percutaneous central venous catheters, tunneled central venous catheters, PICCs, and implanted subcutaneous ports.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 724

OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance. TOP: Central Venous Access Devices (CVADs)

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

COMPLETION

1. Fluids that have the same osmolality as body fluids are used most often to replace extracellular volume and are known as _______________ fluids.

ANS:

isotonic

Isotonic fluids have the same osmolality as body fluids and are used most often to replace extracellular volume (e.g., prolonged vomiting). Isotonic fluids effectively mimic the bodys fluid loss in the absence of an electrolyte imbalance.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 694

OBJ: Discuss patient conditions requiring intravenous (IV) therapy.

TOP: Isotonic Fluids KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. _________________________ pull fluid into the vascular space by osmosis, resulting in an increased vascular volume that possibly will result in pulmonary edema.

ANS:

Hypertonic solutions

Hypertonic solutions pull fluid into the vascular space by osmosis, resulting in an increased vascular volume that possibly will result in pulmonary edema.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 694

OBJ: Discuss complications of IV therapy. TOP: Hypertonic Fluids

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

3. The nurse is caring for a patient who will be on long-term antibiotic therapy. The patient has had numerous IVs in the past, but because the upcoming therapy will be given on a long-term basis, the nurse suggests that a _________________ be inserted.

ANS:

central venous access device (CVAD)

CVADs, which include nontunneled and tunneled catheters, PICCs, and implanted ports, are designed for long-term use.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 724

OBJ: Discuss patient conditions requiring intravenous (IV) therapy.

TOP: Central Venous Access Devices (CVADs)

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

4. The nurse is caring for a patient who has a peripheral IV. While performing her routine assessment, she notes that the insertion site is pale, cool, and edematous. The patient indicates that the site is also painful to the touch. The nurse recognizes these symptoms as revealing a possible _______________.

ANS:

infiltration

Infiltration is indicated by swelling and possible pitting edema, pallor, coolness, pain at the insertion site, and a possible decrease in flow rate.

DIF: Cognitive Level: Analysis REF: Text reference: p. 707

OBJ: Discuss complications of IV therapy. TOP: Infiltration

KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

5. ___________________ is manifested by decreased urine output, dry mucous membranes, decreased capillary refill, a disparity in central and peripheral pulses, tachycardia, hypotension, and shock.

ANS:

Fluid volume deficit (FVD)

FVD is manifested by decreased urine output, dry mucous membranes, decreased capillary refill, a disparity in central and peripheral pulses, tachycardia, hypotension, and shock.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 707

OBJ: Discuss complications of IV therapy.

TOP: Fluid Volume Deficit KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

6. The nurse is caring for a patient who is receiving IV fluids at a rate of 150 mL per hour. During her assessment, the nurse notes that the patient is having more labored respirations, and that crackles have developed in the patients lungs. The nurse reduces the IV rate and notifies the physician. She does this while recognizing that the patient is experiencing signs of _______________.

ANS:

fluid volume excess (FVE)

FVE is manifested by crackles in the lungs, shortness of breath, and edema.

DIF: Cognitive Level: Analysis REF: Text reference: p. 707

OBJ: Discuss complications of IV therapy.

TOP: Fluid Volume Excess KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

7. While assessing the patients IV site, the nurse notes that the site is reddened and warm. The patient states that it is sore. The nurse recognizes these as signs of ____________.

ANS:

phlebitis

Phlebitis is indicated by pain, increased skin temperature, and erythema along the path of the vein.

DIF: Cognitive Level: Application REF: Text reference: p. 707

OBJ: Discuss complications of IV therapy. TOP: Phlebitis

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

8. An electronic device that delivers a measured amount of intravenous fluid over a specified period (e.g., 100 mL/hr) using positive pressure is called an ___________________.

ANS:

electronic infusion device (EID)

An EID delivers a measured amount of fluid over a specified period (e.g., 100 mL/hr) using positive pressure. EIDs use an electronic sensor and an alarm that signals if the pressure in the system changes and the desired flow rate is altered.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 709

OBJ: Explain how to prepare the patient and the family for IV therapy.

TOP: Electronic Infusion Device (EID) KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

9. Intravenous pumps that have built-in software programmed from health care pharmacy databases with unit-specific profiles are known as ______________.

ANS:

smart pumps

A new generation of IV infusion safety systems reduce medication administration errors. Known as smart pumps, they are designed to serve as a final step in preventing errors that relate directly to administration of IV medications. They have built-in software programmed from health care pharmacy databases with unit-specific profiles.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 709

OBJ: Explain how to prepare the patient and the family for IV therapy.

TOP: Smart Pumps KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

10. An intravenous catheter that is inserted through a large arm vein and is advanced until the tip enters the central venous system is known as a __________________.

ANS:

peripherally inserted central catheter (PICC)

A PICC is inserted through a large arm vein (e.g., cephalic or basilic vein) and is advanced until the tip enters the central venous system in the lower third of the superior vena cava.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 724

OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance. TOP: Peripherally Inserted Central Catheter (PICC)

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

11. Intravenous catheters that are inserted directly through the skin and into the internal or external jugular, subclavian, or femoral vein for up to several weeks are known as _______________.

ANS:

nontunneled percutaneous venous access devices

Nontunneled percutaneous venous access devices are inserted directly through the skin and into the internal or external jugular, subclavian, or femoral vein. The tip of the catheter rests in the superior vena cava. These catheters may be left for anywhere from several days up to several weeks.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 724

OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance. TOP: Nontunneled Percutaneous Central Venous Catheters

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

12. _________________________ are surgically inserted through a tunnel into subcutaneous tissue, usually between the clavicle and the nipple, into the internal jugular or subclavian vein, with the catheter tip resting in the distal end of the superior vena cava. The subcutaneous tunnel allows the catheter to remain in place for months to years.

ANS:

Tunneled central venous catheters

Tunneled central venous catheters are surgically inserted through a tunnel into subcutaneous tissue, usually between the clavicle and the nipple (Figure 28-7), into the internal jugular or subclavian vein, with the catheter tip resting in the distal end of the superior vena cava. The subcutaneous tunnel allows the catheter to remain in place for months to years.

DIF: Cognitive Level: Knowledge REF: Text reference: pp. 724-725

OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance. TOP: Tunneled Central Venous Catheters

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

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