Deck 18: Administering Intravenous Therapy

Question 1

Which aspect of intravenous therapy could the nurse safely delegate to the unlicensed assistive personnel (UAP)?

A)Watching the IV insertion site of the client who complained of pain at the site
B)Changing the IV site dressing on the client's left hand
C)Reporting client's complaints of pain or leakage from the IV site when bathing the client
D)Replacing client's IV solution when bag runs dry if it is only D₅W,without medications added

Answer 1

Reporting client's complaints of pain or leakage from the IV site when bathing the client

Question 2

The nurse is setting up an IV infusion on an electronic infusion pump.After leaving the room,the pump alarms and reads high pressure.Which is the priority action by the nurse?

A)Resetting the pump to resume infusion
B)Discontinuing the client's IV access and restarting in a different area
C)Assessing the client's IV site and the tubing for kinks or closed roller clamps
D)Asking the client if the pump has been tampered with in any way

Answer 2

Assessing the client's IV site and the tubing for kinks or closed roller clamps

Question 3

The nurse is initiating IV therapy for an adult client who requires IV fluid infusion for 2-3 days and might require blood administration.Which would the nurse choose as the best option for IV catheterization?

A)Butterfly
B)Huber needle
C)Angiocatheter
D)Implantable venous access device

Answer 3

Angiocatheter

Question 4

The nurse is caring for a client with an IV line continuously infusing solution containing dextrose and water.The client complains of a burning pain along the course of the vein,and the nurse assesses the site to find redness,warmth,and mild swelling at the site.Based on these assessment findings,which term will the nurse use when documenting these findings?

A)Phlebitis at the IV insertion site
B)IV infiltrate
C)Extravasated vesicant drug
D)Extravasation

Question 5

The nurse receives an order to administer 3 liters of IV fluid over the next 24 hours.The infusion device would be set to administer how many mL per hour?
____ mL/hour

Question 6

After changing the client's central line dressing,which items will the nurse include in the documentation of the procedure?

A)Fluid infusing into the catheter
B)Assessment of the central line insertion site
C)Type of dressing applied
D)Aseptic technique under which the dressing was changed
E)Client complaints or concerns

Question 7

When removing an old central line dressing,which action by the nurse is the priority?

A)Pulling the tape off in the direction of the catheter
B)Inspecting the insertion site for signs of infection
C)Pressing the catheter into the client's skin while removing the tape
D)Applying sterile gloves

Question 8

The nurse is caring for a client with a central venous catheter used for intermittent medication administration.When flushing the catheter prior to administering the next dose of medication,which initial action by the nurse is the most appropriate?

A)Aspirating the catheter for blood
B)Obtaining a 3 mL syringe and filling it with normal saline for flushing the line
C)Flushing the catheter,using as much force as required in order to clear the line
D)Positioning the client in reverse Trendelenburg position

Question 9

The nurse initiating IV therapy is preparing a solution to which potassium chloride has been added.After adding the medication,which action by the nurse regarding the IV label is appropriate?

A)Writing the time the IV solution needs to be changed
B)Placing it upside-down on the container
C)Putting it around the IV tubing
D)Documenting the size of the angiocatheter inserted to obtain IV access

Question 10

The nurse begins a blood transfusion,and comes back in 15 minutes to assess the client.The client complains of suddenly feeling cold and is shivering.The client's blood pressure has decreased since the last assessment.Which is the nurse's priority action?

A)Notify the health care provider.
B)Monitor the client's blood pressure every 5 minutes.
C)Stop the blood infusion,and run the normal saline on the other side of the Y tubing.
D)Stop the blood infusion,and remove the tubing from the IV catheter,replacing it with normal saline.

Question 11

The nurse discontinues the client's IV prior to discharge.After removing the catheter,which actions by the nurse are appropriate?

A)Applying pressure to the insertion site until bleeding stops
B)Examining the removed catheter to ensure that it is intact
C)Teaching the client to inform the nurse if the site begins to bleed at any time
D)Holding the client's extremity below the level of the heart if bleeding persists
E)Covering the venipuncture site with a sterile dressing

Question 12

The nurse is caring for a client with a medical diagnosis of increased intracranial pressure.Which IV fluid order would the nurse accept without questioning?

A)Run normal saline at 125 mL/hour.
B)Run 5% dextrose in water at 80 mL/hour.
C)Run 5% dextrose in 0.45% NaCl at 75 mL/hour.
D)Run half-normal saline at 200 mL/hour.

Question 13

The nurse is performing venipuncture to initiate IV therapy.The venipuncture site is chosen based on which indicators?

A)Using the client's dominant arm,whenever possible
B)Choosing a relatively straight vein
C)Avoiding sclerotic veins
D)Looking for a site sufficiently distal to joints
E)Choosing a vein that is visible in addition to palpable

Question 14

The nurse working in the emergency department is caring for a client who experienced deep-thickness burns over 40% of the body and is in shock.Which prescription does the nurse anticipate for this client?

A)Electrolyte solutions
B)Volume expanders
C)Nutrient solutions
D)Total parenteral nutrition

Question 15

Which clients may benefit from central venous IV access?

A)The client requiring long-term IV therapy
B)The client receiving caustic IV therapy
C)The client requiring numerous IV infusions that are not compatible and cannot be infused together
D)The unstable client requiring reliable IV access for administration of medications required immediately
E)The client who is afraid of needles and does not want a catheter in the peripheral extremity

Question 16

The nurse caring for a client receiving parenteral nutrition via a central venous catheter determines that the client's temperature is elevated,white blood cell count is elevated,and the client is lethargic.The nurse suspects the client is septic.Which actions by the nurse are appropriate in this situation?

A)Replacing the parenteral nutrition with a normal saline solution
B)Changing the IV tubing
C)Saving the remaining TPN
D)Recording the lot number of the TPN
E)Notifying the health care provider.

Question 17

The nurse is caring for a client who is to have a peripherally inserted central catheter (PICC)line inserted tomorrow afternoon.The client's peripheral access line is infiltrated,and needs to be restarted.Which site would the nurse avoid using?

A)Median cubital vein
B)Cephalic vein
C)Radial vein
D)Dorsal metacarpal veins

Question 18

The nurse caring for a client with IV access accidentally infuses an air embolism.Which is the highest-priority action of the nurse?

A)Notifying the health care provider
B)Notifying the charge nurse
C)Assessing the client
D)Positioning the client in left Trendelenburg and applying oxygen