1. The health care provider is planning to discontinue total parenteral nutrition for a patient who has been receiving it for 3 weeks after an episode of
... [Show More] severe gastrointestinal (GI) bleeding. What patient care order should the nurse anticipate? 2. The nurse is preparing to insert an intravenous (IV) catheter in a newly admitted patient. Which area should the nurse use first for this catheter? 3. The IV infusion pump for a patient receiving an IV ther- apy begins to alarm and displays occlusion. When the silence button is pushed, the alarm quickly resumes. Which action should the nurse take first? 4. Assessment of blood glucose levels is prescribed every 6 hours for a patient who is receiving parenteral Taper PN rate and introduce regular feedings slowly. Hand Check for kinking of the tubing or a closed clamp. PN contains a lot of sugar. We mon- nutrition (PN). The patient asks why this is necessary. itor blood glucose Which response by the nurse is most appropriate? 5. The nurse notes that a patients central venous access device (CVAD) infusion site gauze dressing is saturat- ed with blood. What should the nurse do? 6. An angiocatheter site in a patients left forearm has become red and tender. What should the nurse do first? 7. As soon as the nurse begins to insert an IV catheter in the patients antecubital space, a hematoma forms at the site. What should the nurse do first? 8. The nurse is preparing heparin to use as a flush for a patients IV infusion site. For which type of site is the nurse providing care? 9. A patient in an outpatient oncology clinic is going to have a peripherally inserted central catheter (PICC) to be sure it doesnt get too high. Change the dress- ing. Remove the an- giocatheter. Remove the catheter and ap- ply pressure to the site. CVAD A PICC line is an IV device that line placed and wants to know what that means. What is the best response by the nurse? 10. An IV infusion is not running. The insertion site looks normal. Which action should the nurse take to try to get it to run again? 11. A patient is in the intensive care unit with acute renal failure secondary to septic shock and is receiving IV fluids of 0.9% NaCl at 125 mL/hr. The patient develops crackles in the lungs, distended neck veins, 1+ pitting edema in the feet, and a 4-pound weight gain from the previous day. What nursing diagnosis is most appro- priate for this situation? 12. An IV insertion site begins to leak, and the tape over the site is wet. What should the nurse do first? 13. The nurse needs to dilate a patients vein prior to inserting an IV catheter. Which technique should the nurse use to dilate the patients vein? 14. Upon entering a patients room, the licensed practical nurse (LPN) notes a white precipitate forming in the IV tubing at the site of a piggybacked antibiotic. What should the nurse do first? 15. A patients IV fluids are infusing too quickly despite adjustments made to the flow rate. Which approach should the nurse consider to slow the flow rate of a gravity solution? 16. 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? is inserted into your arm and ends in the circulation near your heart. Reposition the ex- tremity. Excess fluid vol- ume Remove the dressing from the IV site, and ob- serve the insertion site. Apply a tourniquet for up to 3 minutes. Stop the infusion. Flexing the ex- tremity above the insertion site Fluid moves from the interstitial 17. The nurse suspects a patient receiving IV therapy is experiencing fluid overload. Which assessment should the nurse perform first? 18. A patient is prescribed IV fluid to replace electrolytes and expand plasma volume. Which type of fluid will the nurse provide to the patient? 19. When assessing a patient with an IV line in the right arm, the LPN notices that the skin near the infusion site is taut and cool, and when the arm is lowered, it appears to swell. What should the nurse consider is occurring with this patients IV access site? 20. At a monthly staff meeting, the nurse manager an- nounces that all central line insertion and dressing kits will now come bundled with 2% chlorhexidine gluconate for site preparation and cleansing. Which evidence best supports this decision? 21. The nurse is preparing to flush a patients intermittent IV catheter. Why is the nurse flushing this catheter? 22. The nurse is preparing to administer a bolus IV med- ication through a patients saline lock. Which action should the nurse take immediately before providing the patient with this medication? 23. A patient is prescribed to receive two units of packed red blood cells. When preparing for this patients in- fusion of blood, which type of IV solution should the licensed practical nurse/licensed vocational nurse LPN/LVN select? space into the ve- nous circulation. Assess lung sounds for crack- les. Hypertonic solu- tion Infiltration Chlorhexidine glu- conate (CHG) is the preferred prep solution of choice based on scientific evidence. To ensure the patency of the catheter Cleanse the hub for 15 seconds. 0.9% Normal Saline 24. 24. A patient is prescribed to receive a continuous infu- Ask the physician sion of IV fluids. When preparing to place the catheter, where to place the the nurse notes that the client has a dialysis fistula in the right arm and had a left breast mastectomy three years prior. What should the nurse do? 25. After preparing the skin for IV catheter placement, the nurse decides that the vein needs to be palpated before introducing the catheter. How should the nurse perform this action? 26. The nurse analyzes the fluid volume status of as- signed patients. Which patients are most likely to need continuous IV therapy? (Select all that apply.) 27. The nurse is concerned that a patient is developing complications from peripheral IV therapy. For which systemic complication should the nurse assess the patient? (Select all that apply.) catheter. Apply sterile gloves before palpating the cleansed skin site. A 16-year-old girl with anorexia who has been repeat- edly purging A 3-year-old who has had frequent diarrhea and vom- iting for 3 days An 85-year-old man with Alzheimers dis- ease who refuses to eat or drink Septicemia Air embolism Fluid overload 28. The nurse is preparing to start a peripheral IV infusion. Use a tourniquet Which technique should the nurse use to help ensure success with the venipuncture? (Select all that apply.) to dilate the vein. Apply a warm compress prior to site preparation. 29. The nurse is planning to insert an IV catheter into a patient with severe upper extremity edema. Which actions should the nurse take to ensure the catheter is placed appropriately? (Select all that apply.) 30. A patient is prescribed an IV antibiotic medication that is 100 mg in 50 mL D5W to be infused over 20 minutes. The infusion set delivers 15 gtt per mL. How many drops of medication per minute should the infusion set deliver to the patient? 31. A patient is to receive an IV liter of normal saline over 6 hours. To deliver the fluid, how many mL per hour should the nurse set the pump? Select a catheter that is 2 inches in length. Bring three tourni- quets to the pa- tients bedside. Displace edema to visualize the pa- tients veins. 38gtt/min 167 mL/hr [Show Less]