ATI Fundamentals Chapter 49: Intravenous Therapy Questions – Flashcards
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A nurse is demonstrating how to insert an IV catheter. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure? a. "I will thread the needle all the way into the vein until the hub rests against the insertion site after I see a flashback of blood" b. "I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up" c. "I will apply pressure approximately 1.2 inches below the insertion site prior to removing the needle" d. "I will choose a vein in the antecubital fossa for IV insertion due to its size and easily accessible location"
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b. "I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up" The nurse should use a smooth, steady motion to insert the catheter through the skin at angle of 10 to 30 degrees with the bevel up. This is the optimal angle of preventing the puncture of the posterior wall of the vein.
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A nurse is collecting data from a client who is receiving IV therapy and reports pain in his arm, chills, and not feeling well. The nurse notes warmth, edema, induration, and red streaking on the client's arm close to the IV insertion site. Which of the following actions should the nurse plan to take first? a. obtain a specimen for culture b. apply a warm compress c. administer analgesics d. discontinue the infusion
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d. discontinue the infusion The greatest risk to this client is injury from infection. The first action the nurse should take is to stop the infusion and remove the catheter might be the source of infection.
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During new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by an orientee indicates understanding of the preventative strategies? a. "I will leave the IV catheter in place after the client completes the course of IV antibiotics" b. "As long as I am working with the same client, I can use the same IV catheter for my second insertion attempt." c. "If my client needs to use the rest room, it would be safer to disconnect his IV infusion as long as I clean the injection port thoroughly with an antiseptic swab." d. "I will replace any IV catheter when I suspect contamination during insertion"
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d. "I will replace any IV catheter when I suspect contamination during insertion" Nurses should replace IV catheters when suspecting any break in surgical aseptic technique, such as in emergency insertions.
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A nurse on the IV team is conducting an in-service education prorgram about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply) a. "The temperature around the IV site is cooler." b. "The rate of the infusion increases" c. "The skin at the IV site is red" d. "The IV dressing is damp" e. "The tissue around the venipuncture site is swollen"
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a. "The temperature around the IV site is cooler" d. "The IV dressing is damp" e. "The tissue around the venipuncture site is swollen. A decrease in skin temperature around the site is a manifestation of infiltration due to the IV solution entering the subcutaneous tissue around the venipuncture site. A damp IV dressing is a common finding with infiltration due to the IV solution entering the subcutaneous tissue and leaking out through the venipuncture it. Swollen tissue around the venipuncture site is a manifestation of infiltration due to the IV solution entering the subcutaneous tissue and causing swelling, as the fluid is no longer infusing into the vein
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A nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride IV at 120 mL/hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? (select all that apply) a. "I feel lightheaded" b. "I feel as though my heart is racing" c. "I feel a little short of breath." d. "The nurse technician told me that my blood pressure was 150 over 90." e. "I think my ankles are less swollen"
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b. "I feel as though my heart is racing" c. "I feel a little short of breath" d. "The nurse technician told me that my blood pressure was 150 over 90" A manifestation of fluid overload is tachycardia due to the increased blood volume, which causes the heart rate to increase. A manifestation of fluid overload is shortness of breath or dyspnea due to the increased amount of fluid entering the air spaces in the lungs, which reduces the amount of circulating oxygen A manifestation of fluid overload is hypertension due to the increased blood volume, which causes the blood pressure to increase
