Deck 27: Intravenous and Vascular Access Therapy

Question 1

The nurse prepares to relocate an intravenous catheter because of signs of infiltration. The IV was located in the patient's nondominant hand.Which criterion would be best for the nurse to use when deciding on the location of the new intravenous (IV)site?

A) Use a site distal to the original site.
B) Place it wherever a vein is suitable.
C) Place the new site at a venous bifurcation.
D) Continue to use the nondominant extremity.

Answer 1

Place it wherever a vein is suitable.

Question 2

The nurse is caring for a patient with a peripheral intravenous access that is used intermittently for medications but is not a continuous infusion.Which technique should the nurse use for routine care of this peripheral line?

A) Flush with a low concentration of heparin.
B) Always change the end cap with each medication dose.
C) Change the intravenous (IV) insertion site every day.
D) Flush with 0.9% saline solution.

Answer 2

Flush with 0.9% saline solution.

Question 3

The healthcare provider prescribes 500 mL of 0.25% normal saline (1/4 NS)intravenously over 4 hours for the patient.At which rate does the nurse infuse the intravenous (IV)solution into the patient using IV tubing with a drop factor of 15 gtts/mL?

A) 125 mL/hr
B) 31 mL/min
C) 31 gtts/min
D) 125 gtts/min

Answer 3

31 gtts/min

Question 4

The nurse infuses a unit of blood,but after 4 hours the blood infusion is not complete.Which action should the nurse implement?

A) Check the intravenous (IV) access for patency.
B) Increase the infusion rate of the blood.
C) Discontinue the blood infusion.
D) Assess the patient for an ABO mismatch.

Question 5

The nurse is trying to access the best insertion site on a patient.Which principle would the nurse use to achieve this goal?

A) Avoid using soft, bouncy veins.
B) Choose the patient's best proximal vein.
C) Choose a site large enough for adequate blood flow.
D) Always use the smallest-gauge intravenous (IV) catheter available.

Question 6

The nurse feels resistance while trying to flush the intravenous (IV)line with a 5-mL syringe of normal saline solution before administering a medication by IV bolus.Which should the nurse implement next?

A) Use a 3-mL syringe to flush.
B) Aspirate the IV line for a blood return.
C) Check for causes of resistance.
D) Inject the IV medication slowly.

Question 7

After inserting a peripheral intravenous (IV)line into the patient,the nurse provides patient teaching about the IV insertion site.What information should the nurse give to the patient?

A) Expect minor pain at the insertion site.
B) Report redness at the insertion site.
C) Remain on bed rest with the IV infusion.
D) Disconnect IV tubing to change a gown.

Question 8

The patient has an intermittent infusion device inserted in the hand.Which strategy should the nurse use related to prevention of dislodging the patient's intravenous (IV)access?

A) Instruct the patient how to protect the IV site.
B) Apply a new sterile dressing every day.
C) Change the IV tubing at least daily.
D) Flush the IV catheter every morning.

Question 9

The nurse is setting up to administer a unit of blood.Which is the most important nursing intervention during preparation for this procedure?

A) Prepare a normal saline solution.
B) Obtain a Y-tubing for administration.
C) Provide the patient with information.
D) Identify the blood product and patient.

Question 10

The nurse is preparing to administer blood.What solution is most appropriate for the nurse to use when priming the blood administration set?

A) 0.45 normal saline
B) 0.9 normal saline
C) D5 0.45 normal saline
D) Dextrose 5% in water

Question 11

The patient has a peripheral infusion for the administration of antibiotics.Which action is most effective for the nurse to use to detect an intravenous (IV)therapy-related infection?

A) Use clean technique for dressing changes.
B) Palpate the insertion site through the dressing.
C) Change the IV tubing at 12-hour intervals.
D) Routinely apply an antimicrobial to the IV site.

Question 12

The nurse assesses the patient's intravenous (IV)insertion site and notes that it is warm,red,and tender.Which intervention should the nurse implement first?

A) Slow the infusion rate.
B) Discontinue the IV infusion.
C) Apply cool compresses.
D) Apply warm compresses.

Question 13

The prescription for the patient's intravenous (IV)infusion reads,"100 mL/hr." The nurse observes that the patient's IV line infused 125 mL in addition to the ordered volume after 2 hours.Which is the most important intervention for the nurse to implement?

A) Compare weight to baseline data.
B) Replace the infusion pump batteries.
C) Assess the patient for respiratory distress.
D) Reduce the infusion rate below 75 mL/hr.

Question 14

The nurse assesses the patient's intravenous (IV)infusion.Which clinical indicator cues the nurse to take special precautions while infusing IV fluids?

A) Poor skin turgor
B) Bilateral crackles
C) Mild hypotension
D) High serum sodium

Question 15

The nurse is explaining to nursing assistive personnel (NAP)how to help maintain the patient's intravenous (IV)therapy.What action regarding IV therapy can be delegated to the NAP?

A) Adjusting the infusion rate
B) Changing the IV dressing
C) Reporting patient complaints
D) Administering IV antibiotics

Question 16

The nurse observes fine white crystals in the intravenous (IV)tubing that is infusing an antibiotic.Which action should the nurse take?

A) Tell the patient that this is a common occurrence.
B) Stop the infusion and notify the healthcare provider.
C) Flush the tubing with normal saline solution.
D) Attach a 0.22-micrometer inline intravenous (IV) filter.

Question 17

The healthcare provider's order reads,"Administer 5% dextrose solution with normal saline (D?NS)intravenously now." Which should the nurse implement next?

A) Infuse a bolus of D5NS to the patient now.
B) Regulate an intravenous (IV) infusion pump at 125 mL/hour.
C) Call the healthcare provider to clarify the order.
D) Perform venipuncture with a butterfly needle.

Question 18

The nurse observes that the patient's left cephalic intravenous (IV)site is cool,swollen,and mildly tender,although the IV line is infusing at the prescribed rate.Which action should the nurse take first?

A) Instruct the patient to elevate his or her arm on two pillows.
B) Discontinue the IV infusion and start one in the right arm.
C) Apply a warm, moist compress to the IV site.
D) Reassess the IV site in 2 hours for any change.

Question 19

The nurse is preparing to insert a peripheral intravenous (IV)line.Which technique should the nurse implement to prepare for the IV insertion?

A) Slap the selected vein gently several times.
B) Select a proximal site on the extremity.
C) Shave the hair in the area of the insertion site.
D) Tie a tourniquet above the selected insertion site.

Question 20

The nurse prepares to administer blood to the patient.Which is the nurse's priority action?

A) Determining patient history of autologous blood donations
B) Assessing patient baseline vital signs before the transfusion
C) Confirming the rate of the blood infusion with the healthcare provider
D) Identifying patient blood type, cross-match, and blood product

Question 21

The nurse is preparing to change the intravenous (IV)solution after the current one infuses.What action is appropriate for the nurse to take to provide for a smooth transition from the empty bag to the new one?

A) Hang another bag of the identical IV solution.
B) Change the tubing when preparing a new IV bag.
C) Allow IV fluid to empty into the upper part of the tubing.
D) Obtain the next solution bag approximately 1 hour ahead.

Question 22

The nurse observes bleeding on the dressing of a site where the IV was discontinued.Which action should the nurse take first?

A) Hold pressure on the site.
B) Replace the dressing.
C) Apply a warm compress.
D) Lower the site below the level of the heart.

Question 23

A 5-year-old patient has intravenous (IV)fluids prescribed at 40 mL/hr,through microdrip tubing.Which rate does the nurse use to infuse the patient's IV fluid?

A) 20 gtts/min
B) 25 gtts/min
C) 40 gtts/min
D) 60 gtts/min

Question 24

The nurse administers blood to the patient and observes that the patient has tachycardia,chills,and lower back pain.Which should the nurse implement first?

A) Notify the healthcare provider.
B) Notify the blood bank.
C) Complete the vital signs.
D) Remove the intravenous (IV) tubing.

Question 25

The prescription for the patient's intravenous (IV)fluid reads,"Infuse 1000 mL over 10 hours." At which rate does the nurse infuse the IV fluids using IV tubing with a drop factor of 15 gtts/mL?

A) 20 gtts/min
B) 25 gtts/min
C) 30 gtts/min
D) 32 gtts/min

Question 26

A patient in the emergency department needs a blood transfusion of A- blood, and none is available. Nursing care would be correct if the nurse administered blood of which type?

A) A+
B) O+
C)O-
D)AB-

Question 27

A patient on an anticoagulant is going home and needs his peripheral intravenous (IV)line removed.Which action is essential for the nurse to take?

A) Pull the IV catheter out smoothly but quickly.
B) Apply sterile gloves before going to the patient's bedside.
C) Check the most recent clotting studies.
D) Apply pressure over the insertion site after removal of the IV line for 5 to 10 minutes.

Question 28

The order calls for the patient to receive 500 mL of intravenous (IV)fluid over 4 hours,and the nurse uses IV tubing with a drop factor at 10 gtts/mL.Which rate should the nurse use on an electronic infusion pump for IV fluids to administer this prescription?

A) 125 mL/hr
B) 500 mL/hr
C) 21 gtts/min
D) 32 gtts/min

Question 29

The nurse assesses the patient's intravenous (IV)site.Which clinical indicator does the nurse recognize as being most consistent with phlebitis?

A) An elevated heart rate
B) Decreased skin temperature
C) Erythema along the vein line
D) Edema around the insertion site

Question 30

The nurse is caring for a patient with a peripheral intravenous (IV)line.What should the nurse do during the IV site dressing change to prevent accidental dislodgement of the IV catheter?

A) Stabilize the IV catheter until the tape is in place.
B) Place folded gauze under the IV catheter hub.
C) Wear clean gloves to remove the old dressing.
D) Clean in a circular motion away from the site.

Question 31

The nurse is preparing to initiate a blood transfusion.Which step of the procedure should the nurse implement first?

A) Begin the infusion at 2 mL/min.
B) Establish a single-line infusion.
C) Check vital signs in 30 minutes.
D) Shake the blood gently to mix the preservative.

Question 32

2. _________ _________is a specialized form of nutritional support in which nutrients are given intravenously (IV)through a CVAD by an infusion pump to patients with significant gastrointestinal (GI)dysfunction.

Question 33

The nurse is trying to get an intravenous (IV)line to last several days.What responsibility does the nurse have related to the assessment and maintenance of a peripheral IV site?

A) Elevating the patient's arm to maintain the ordered flow
B) Padding the IV site for skin protection
C) Inspecting the insertion site on a regular schedule
D) Changing the site every day at the same time

Question 34

The nurse is administering parenteral nutrition via a central venous access device.Which outcome would best substantiate the nurse's assessment that this therapy is effective?

A) The patient gains 4 1/2 pounds in 1 week.
B) The patient's blood glucose stays between 130 and 160.
C) The patient states, "I'm feeling much stronger today."
D) The patient gains 6 pounds over 12 days.

Question 35

1. A ________ infusion occurs when the flow rate is set at an ordered rate and given over a 24-hour period.