According to the Centers for Disease Control, IV sites should be rotated every: - correct answer 48 to 72
Before equipment setup and venipuncture,
... [Show More] _________ seconds of hand washing with an antimicrobial soap are recommended. - correct answer 15 to 30
What are the advantages to Over-the-Needle catheters? - correct answer - easy to insert
- stays patent longer
- catheter tip tapered to prevent peel-back
- radiopaque feature makes x-ray detection easy
- infiltration rare
- winged cannula easy to tape
- stable: allows for greater patient mobility
What are the disadvantages to over-the-needle catheters? - correct answer - depending on the hub, sometimes difficult to secure with tape
- long inflexible stylet increases risk of accidental puncture; pressure marks from hub
- some catheters drag through the skin on insertion
- increased risk of phlebitis
Which statement is true regarding the insertion of an over the needle catheter? - correct answer remove the tourniquet after advancing the catheter into the vein
When starting an I.V., the nurse remembers that a 14 to 16 gauge over the needle catheter may be selected for which of the following? - correct answer multiple trauma, heart surgery, and transplantation procedures
When choosing the Metacarpal vein for IV therapy, the nurse should remember which of the following considerations? - correct answer - this is a good site to begin therapy
- this site is usually easily visualized
- this site should be avoided if infusing antibiotics, potassium chloride, or chemotherapeutic agents
When choosing an IV therapy site always try to: - correct answer select a vein that's straight and will not be disturbed when the patient moves
The nurse should monitor the client receiving infusion therapy at least every: - correct answer 2 hours for adults and one hour for children
IV therapy labels should be on which areas? - correct answer catheter site, tubing, and solution container
Which IV fluid type pulls fluid into the veins from the more dilute area in cells and interstitial space? - correct answer hypertonic
A client is scheduled a test that requires an NPO status and has been ordered 5% Dextrose in water (D5W). The nurse understands which of the following to be the best rational for this action: - correct answer isotonic solutions maintain body fluid balance
A patient is prescribed an IV fluid to replace electrolytes and expand plasma volume. Which type of fluid will the nurse provide to the patient? - correct answer hypertonic solution
Is an isotonic solution good to use? - correct answer yes, because they maintain fluid balance
A patient is prescribed an IV infusion of a hypertonic solution. Which fluid shift should the nurse expect to occur with this type of infusion? - correct answer Fluid moves from the interstitial space into the venous circulation
What are the examples of an Isotonic solution? - correct answer - 0.9% NaCl
- 5% D and 0.2% NaCl
- Lactated Ringer's (multiple electrolyte solution)
- Ringer's injection (MES)
- Normosol-R (MES)
- Plasmalyte-A (MES)
- Isolyte E (MES)
- 10% Dextran and 0.9% NaCl (Specialty solution)
What are some examples of a Hypertonic solution? - correct answer - 10% D/W
- 20% D/W
- 50% D/W
- 70% D/W
- 3% NaCl
- 5% NaCl
- 5% D and 0.9% NaCl
- 5% D and 0.45% NaCl
- 1/6 M Sodium lactate
Total parenteral nutrition is hypertonic. What is the percentage of dextrose in the solution? - correct answer 50% dextrose
What are some examples of hypotonic solutions? - correct answer - 2.5% D/W
- 0.2% NaCl (1/4 strength)
- 0.45% NaCl (1/2 strength)
- 2.5% D and 0.45% NaCl
Why may a patient need to have a central venous catheter? - correct answer for the administration of TPN
What puts patients at risk for the development of phlebitis? - correct answer - infusate
- catheter size
- catheter material
- insertion technique (most common complication of over the needle catheters today)
When performing venipuncture, the nurse may feel a "pop" as he/she enters the: - correct answer tunica adventitia
A patient states that his IV site is sore. You assess the site and note redness and swelling but no signs of palpable cord or streak. It would be staged as a: - correct answer 1+
A patient rings the call light and states that the IV insertion site is painful. The site is reddened, warm and swollen. The nurse assesses that the patient is most likely experiencing: - correct answer phlebitis
When checking the physician's orders prior to initiating cannulations, which of the following should not be included? - correct answer location of IV site
As a nurse, what do you need to check for in the Drs. orders prior to initiating IV therapy? - correct answer - solution
- additive
- dosage
- volume
- rate
- frequency
- route
When performing venipuncture, a nurse should: - correct answer lightly tap the vein after having the patient make a fist several times
What are the methods for vein dilation prior to venipuncture? - correct answer - gravity
- fist clenching
- tapping
- warm compresses
- blood pressure cuff
- tourniquet
When applying a tourniquet, the nurse should apply it so that: - correct answer venous circulation is suppressed distal to the tourniquet
When using a tourniquet to facilitate vein distention, the nurse knows to apply the tourniquet _____ inches above the insertion site. - correct answer 6 to 8
Where do you place a tourniquet on a hypertensive patient? - correct answer You would place it higher up
When selecting tubing, which of the following is most appropriate when the solution must be infused very precisely or at a slow rate? - correct answer microdrip tubing
The opening through which fluid passes from the solution container into the drip chamber determines the drop size. The nurse understands that it is easier to count larger drops; therefore, when infusing a solution by gravity at a fast rate, the nurse would select _____________ tubing. - correct answer macrodrip tubing
A nurse hangs microdrip tubing on a client who needs an IV. How many gtts per ml is delivered with microdrip tubing? - correct answer 60 gtts per ml
Which of the following is the universal recipient? - correct answer type AB
The universal blood donor is: - correct answer type O
Which of the following best describes the anatomy of a vein? - correct answer thin walled, carries deoxygenated blood, valves present
What are the 8 local complications that can occur during IV infusion? - correct answer 1) hematoma
2) thrombosis
3) phlebitis
4) thrombophlebitis
5) infiltration
6) extravasation
7) local infection
8) venous spasm
What are the 6 systemic complications that can occur during IV infusion? - correct answer 1) septicemia
2) circulatory overload
3) pulmonary edema
4) air embolism
5) speed shock
6) catheter embolism
You are performing a venipuncture and an ecchymosis forms over and around the insertion area, which has become raised and hardened. You are unable to advance the cannula into the vein. These are signs of: - correct answer hematoma
Hematoma formation is most often related to what? - correct answer - nicking the vein during unsuccessful venipuncture attempt
- discontinuing an IV cannula or needle without holding pressure over the site
- applying a tourniquet too tightly above a previously attempted venipuncture
The nurse assesses an IV site with a dose of Dopamine infusing. She notes the following findings: edema, blanching, coolness, pain, burning, and blistering at the site. Which of the following should the nurse suspect? - correct answer extravasation
The nurse is aware of the systemic complications of IV therapy. The patient has a peripheral IV of 0.9% NS at 125ml/hr. The nurse's assessment findings are as follows: palpitations, lightheadedness, weakness, dyspnea, cyanosis, chest pain, hypotension, and mental status changes. Which of the following should the nurse suspect? - correct answer air embolism
What are the causes of thrombosis formation? - correct answer - blood backing up in the system of a hypertensive patient
- location of the IV cannula
- trauma to the wall of the vein by the cannula
- low flow rate/obstruction of flow rate
If the nurse suspects that her patient is developing a thrombosis, which of the following interventions should be made? - correct answer - discontinue the cannula and restart with a new catheter in a different site
- apply a cold compress to the site to decrease the flow of blood
- notify the physician and assess for circulatory impairment
The first symptom of a venous vasospasm is: - correct answer sharp pain extending from the site of infusion
Which of the following complications occurs when microorganisms migrate into the bloodstream? - correct answer septicemia
Which systemic complication has a symptom of a mill wheel murmur? - correct answer air embolism
The recommended rate of infusion for one unit of packed red blood cells (PRBC) is no longer than: - correct answer 4 hours
Whole blood is indicated for: - correct answer acute massive blood loss
The nurse must check all of the following with another nurse before initiating transfusion: - correct answer - blood type
- patient name
- unit number of blood
- expiration date
Pre-transfusion testing on the donor blood would include: - correct answer - ABO and RH group determination
- serologic testing for syphilis
- screening for unexpected antibodies
An allergic transfusion reaction to blood is usually caused by: - correct answer antibodies against plasma proteins
The term used for a patient having surgery who donates his own blood is called: - correct answer autologous
When administering a blood transfusion, vital signs should be taken: - correct answer before the transfusion is started, 15 minutes after infusion started, every 30 minutes till completed and one hour after transfusion completed
Tubing used to administer Total Parenteral Nutrition should be changed at which frequency? - correct answer every 24 hours
Which of the following statements concerning TPN are true? - correct answer - multi-vitamins cause the solution to be yellow in color
- solutions must be prepared by the pharmacy
- the IV tubing should be changed every twenty four hours
- Blood glucose should be tested every 4-6 hours or per Drs. orders or facility protocol
The LPN observes a patient receiving TPN for complications of this therapy, which include: - correct answer glucose intolerance
A patient receiving TPN fluid therapy experiences an air embolism in the central line. The nurse should immediately turn the patient onto the: - correct answer left side and lower the head of the bed
What are the complications resulting from receiving TPN? - correct answer - electrolyte imbalances
- essential fatty acid deficiency
- protein sensitivity
Which of the following would be necessary for infusing TPN? Select all that apply. - correct answer - filter
- physician's order
- infusion pump
- fat emulsions infused separately
Are the components of TPN solution the same for all patients? - correct answer no
A patient has started receiving TPN after surgery. The rate will be increased in increments of ______ until the desired rate ordered is reached. - correct answer 25 ml
What are the layers of the vein from outer to inner? - correct answer Tunica adventitia, tunica media, and tunica intima
Which of the following is not considered a crystalloid solution? - correct answer colloid
this type of sensory receptor in the skin processes the tactile sensations; ex. palpate vein - correct answer mechano receptors
this type of sensory receptor in the skin processes cold, warmth and pain - correct answer thermo receptor
this type of sensory receptor in the skin processes pain; ex. when vein is punctured - correct answer Noci receptor
this type of sensory receptor in the skin processes decreasing circulating blood volume - correct answer chemo receptor
this type of sensory receptor in the skin processes position changing; ex. how hand/arm is positioned - correct answer proprioceptor
What are the 3 types of drug compatibilities? - correct answer 1) physical
2) chemical
3) therapeutic
this occurs when one drug is mixed with other drugs or solutions to produce a product unsafe for administration; aka pharmaceutical incompatibility - correct answer physical incompatibility
this is defined as the reaction of a drug with other drugs or solutions, which results in alterations of the integrity and potency of the active ingredient. - correct answer chemical incompatibility
this is an undesirable effect occurring within a patient as a result of two or more drugs being given concurrently - correct answer therapeutic incompatibility
When in doubt about IV drug compatibilities, a good practice is to: - correct answer flush the IV administration set with NS before and after medications are infused
What kind of compatibility problem is it called when a reaction occurs between 2 or more drugs that disrupts how potent the drug is? - correct answer chemical incompatibility
What are crystalloids given for? - correct answer dehydration
The nursing instructor is discussing the different types of IV fluids with the nursing students. What type of fluid would the instructor tell the students is used to replace circulating blood? - correct answer colloid solution
What are the crystalloid solutions: - correct answer - D/W
- NaCl
- multiple electrolytes
- D/NaCl
What are the colloid solutions: - correct answer - 10% mannitol
- 20% mannitol
- NaHCO3
Which of the following can a licensed practical nurse do? Select all that apply. - correct answer - performing calculations and adjusting flow rates
- initiating and discontinuing the administration of IV fluids given via a peripheral route
- changing site dressings and tubing to peripheral lines according to facility policy
- administration of IV investigational drugs
According to the Louisiana State Board of Practical Nurse Examiners, an LPN can do the following IV skills. Select all that apply. - correct answer - initiate and maintain IV therapy and administer IV medications by IVPB
- hang blood and blood products
- hang and monitor TPN infusions
- give medications per IV push
Verbal orders should be written in the medical record and signed by the physician within: - correct answer 24 hours
If the patient doesn't know if they are allergic to iodine prep, what can you ask them instead that they are allergic to? - correct answer seafood
Which of the following assessments best indicates a client's readiness for IV therapy? - correct answer informed verbal consent
Who provides the guidelines for the management of intravascular catheters? - correct answer Centers for Disease Control (CDC)
True or False: In reference to IV Therapy, most malpractice is common law and not administrative law. - correct answer true
Coercion of a rational adult client to insert a cannula is considered which of the following? - correct answer assault and battery
After insertion of a __________, a chest x-ray is taken to confirm catheter placement and to rule out an accidental puncture of the pleural membrane. - correct answer central catheter
What do you need to use when you identify a patient? - correct answer 2 identifiers (name, DOB, wristband, etc.)
If the IV tubing drops onto the floor, what do you need to do next? - correct answer you pick it up, and you go and get a new one.
Can you reuse the same cathlon for another patient or if you have to stick the patient again? - correct answer no, get a brand new one
When you need to remove body hair to start an IV, do you use scissors or a razor? - correct answer scissors because razors increase risk for bacteria
this is an abnormal fluid accumulation in the lungs; fluid leaks through the capillary wall and fills the interstitial and alveoli - correct answer pulmonary edema
What are the signs and symptoms of pulmonary edema? - correct answer - restlessness
- slow increase in pulse rate
- headache
- shortness of breath
- cough
- flushing
Who are at risk for the development of pulmonary edema? - correct answer cardiovascular disease patients and the elderly
this is a systemic reaction caused by rapid injection of a medication into circulation, causing toxic levels of medication in the plasma - correct answer speed shock
What are the signs and symptoms of speed shock? - correct answer - dizziness
- facial flushing
- headache
- tightness in chest
- hypotension
- irregular pulse
- progression of shock
- cardiac arrest
this occurs when a piece of catheter breaks off and travels through the vascular system; it can migrate to the chest and lodge in the pulmonary artery or the right ventricle; this is an infrequent systemic complication of over-the-needle catheters. - correct answer catheter embolism
What are the signs and symptoms of a catheter embolism? - correct answer - sharp sudden pain at IV site
- minimal blood return
- short, rough, and uneven catheter
- cyanosis
- chest pain
- tachycardia
- hypotension
What type of catheters need to always be used to ensure that it is seen on x-ray? - correct answer radiopaque [Show Less]