ATI: IV Therapy Posttest

question

A nurse initiating a peripheral IV infusion punctures the skin and selected vein and observes blood return in the flashback chamber of the IV catheter. Which of the following actions should the nurse perform next? A. Secure the catheter to the skin with a transparent dressing. B. Lower the catheter until it is almost flush with the skin. C. Advance the catheter about 1/4 inch into the vein. D. Remove the stylet slowly from the lumen of the catheter.
answer

B. Lower the catheter until it is almost flush with the skin. Lowering the angle and then advancing the catheter slightly facilitates full penetration of the wall of the vein, thus placing the catheter within the vein’s lumen and making it easy to advance the catheter off the stylet.
question

Which of the following is an important nursing action when converting an IV infusion to a saline lock? A. Open the roller clamp of the primary infusion to prime the saline lock. B. Apply pressure with a syringe to clear resistance in the IV catheter. C. Attach secondary tubing to allow mobility. D. Flush the IV catheter to confirm patency.
answer

D. Flush the IV catheter to confirm patency. It is essential to attach the primed saline lock adapter to the extension tubing and to flush the tubing with normal saline to confirm patency.
question

A patient in early stage renal failure is prescribed an infusion of 0.45% sodium chloride. This type of solution is appropriate because it A. pulls fluid from the cells and increases vascular volume. B. dilutes extracellular fluid and rehydrates the cells. C. replaces extracellular volume and maintains intravascular volume. D. draws fluid into blood vessels and reduces interstitial compartments.
answer

B. dilutes extracellular fluid and rehydrates the cells. Infusing a hypotonic solution such as 0.45% sodium chloride moves fluid into the cells, thus enlarging and rehydrating them.
question

A nurse is removing an IV catheter from a patient whose IV infusion has been discontinued. Which of the following actions is appropriate? A. Apply firm pressure over the vein. B. Leave the roller clamp slightly open. C. Pull the catheter straight back from the insertion site. D. Lift the hub slightly upward away from the skin.
answer

C. Pull the catheter straight back from the insertion site. With the catheter stabilized and using a slow, steady movement, the nurse should withdraw the catheter straight back and away from the insertion site, making sure to keep the hub parallel to the skin.
question

A patient is to receive 1,000 mL of 5% dextrose in lactated Ringer’s over 8 hours. Using tubing with a drop factor of 15 gtt/mL, the nurse should regulate the fluid to infuse at how many drops per minute? (Round the answer to the nearest whole number.)
answer

31 gtt/min A formula for determining an IV flow rate in drops per minute is: volume (mL) x drop factor (gtt/mL) = IV flow rate (gtt/min) time (min) The information from the scenario is: volume (mL) = 1,000 time (min) = 480 drop factor (gtt/mL) = 15 The flow rate (drops to infuse per minute) is determined as follows: 1,000 x 15 = x 480 Then: 15,000 = x480 Then: 31.25 = x The IV flow rate in gtt/min is 31.
question

A nurse has just initiated a peripheral IV infusion of 5% dextrose in water. How often should the nurse plan to replace the primary infusion tubing? A. Every 24 hours. B. Every 48 hours. C. Every 72 hours. D. Every 108 hours.
answer

C. Every 72 hours. The Centers for Disease Control and Prevention recommends changing IV tubing no more often than 72-hour intervals unless the tubing has been contaminated, punctured, or obstructed.
question

A nurse has just inserted a peripheral IV catheter for a continuous infusion. To secure the catheter, the nurse should A. leave the connection between the hub and the tubing uncovered. B. wrap tape around the circumference of the patient’s arm. C. tape the IV catheter’s hub securely to the patient’s skin. D. place a piece of paper tape over the insertion site.
answer

A. leave the connection between the hub and the tubing uncovered. This makes it possible to replace the tubing without removing the dressing.
question

A nurse is discontinuing an IV infusion. For which of the following reasons is it important to verify and document the integrity and condition of the IV catheter? A. A broken-off catheter tip indicates the risk for an embolus. B. Catheter erosion indicates that it was left in place too long. C. Blood within the catheter could indicate clot formation. D. Discoloration of the catheter could be a sign of phlebitis.
answer

A. A broken-off catheter tip indicates the risk for an embolus. The tip of the catheter can break off, thus creating an embolus. To limit the movement of the embolus, the nurse should apply a tourniquet high on the extremity where the IV line was located and notify the provider immediately.
question

A nurse who has just initiated an IV infusion explains to the patient that complications are possible and that she will monitor the infusion regularly. The nurse should teach the patient that which of the following findings is an indication of early infiltration? A. Moisture B. Bruising C. Tingling D. Coolness
answer

D. Coolness Coolness is a classic sign of infiltration, along with swelling, pallor, and possibly tenderness. Infiltration is a leakage of IV solution out of the intravascular compartment into the surrounding tissue.
question

A nurse finds a patient’s IV insertion site red, warm, and slightly edematous. Which of the following actions should the nurse perform first? A. Check for a blood return. B. Elevate the extremity. C. Discontinue the IV line. D. Apply warm, moist heat.
answer

C. Discontinue the IV line. The patient has classic signs of phlebitis, an inflammation of the vein. The IV line must be discontinued immediately to reduce the risk of thrombophlebitis and embolism.

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