question

Patients benefiting form longterm vascular access devices include

answer

Adults receiving vesicants and irritants such as chemo; an elderly, dehydrated, and diabetic patient w/ poor peripheral circulation; patients expected IV antibiotic therapy 7 days or greater for severe respiratory infection; patients being managed at home for end stage cancer w/ cont, IV of opioids, patient having major abdominal surgery requiring TPN nutrition; patient requiring frequent long term phlebotomy treatment for polycythemia.

question

What are the two most complications of CVA device?

answer

Occlusion and infection

question

When should Xray be obtained for tunneled CVAD?

answer

If symptoms of displacement are present and before using the first time

question

The nurse is starting a continuous infusion on a patient with CVAD. Unable flush the cath, what actions should the nurse take?

answer

Have patient cough or breath deep, reposition patients, have patient raise arms, making sure tubing is kink free and unclamped. If unsuccessful, notify HCP. infusing fluids by gravity would be successful if there is an occlusion. Need MD order for thrombolytic. Never use syringe smaller than 5 ml psi is too great could cause migration.

question

Catheter migration

answer

irregular heart rate or dysrhythmia

question

Thrombosis

answer

pain numbness in neck and shoulder

question

Occlusion

answer

absent blood return, sluggish infusion

question

Patient w/tunneled CVAD , nurse cleaning exit site observes purulent drainage and redness. Upon reviewing chart she notices patients been febrile w/ elevated WBC for the past 24 hr. Pt alert w/decrease U/O. Med records indicate he has been receiving parenteral nutrition. What actions should nurse take?

answer

Pt has local and systemic infection. HCP should be notified for further instruction which may include Blood culture and admin of antibiotics

question

Nurse is changing dressing on PICC line and notices patients arm is swollen and cool to touch. Patient has been infusing nutrition, client states machine beeping a lot and silencing it. Extravasation os suspected what action should nurse take?

answer

First stop infusion. May admin antidote per protocol for vesicant drug Notify HCP Apply warm compress & emotional support PiCC line should remain in place until removal order Inform patient purpose and importance of alarm Never scold a patient

question

Nurse is obtaining blood sample from CVAD. What complication could arise if she forgets to clamp catheter tip before capping

answer

Air embolus

question

What position should patient be placed if experiencing an air embolism?

answer

Trendelenburg's position

question

Air Embolus

answer

cyanosis, dyspnea

question

Advantage of CVAD line

answer

can stay in longer patient can receive longterm therapy with related access

question

dressing change supplies for CVAD include

answer

clean to remove dressing and should be removed in direction catheter was inserted,sterile gloves to apply new, transparent dressing (change5-7 days) or sterile gauze( every 48 hours), tape, antimicrobial swabs clean site horizontal, vertical and circular motion, masks

question

Large vein for CVAD is necessary

answer

because the larger lumen minimizes risk of complications to vessels like irritation, inflammation sclerosis

question

Which two devices are considered permanent

answer

Tunneled CVAD and implanted venous port

question

Can strained nurse insert PICC line

answer

yes

question

Complications of PICC line

answer

sepsis, air embolus, thrombosis, occlusion, phlebitis

question

PICC line

answer

usually located antecubital fossa

question

Implanted venous port

answer

requires surgical implantation and should be flushed with 3-5 ml of heparin monthly

question

the nurse KNOWS....a 3 ml syringe should never be used to flush a CVAD but why?

answer

3 ml syringes exert too high a psi, a 10 ml syringe is used to minimize pressure.

question

Can blood pressure be taken in the arm of the PICC or MCL line

answer

No, but can be taken on both arms of CVAD

question

When taking blood sample from an implanted venous port the nurse should aspirate?

answer

and discard 5 ml of blood before obtaining sample to avoid dilution from initial saline flush, sterile gloves are necessary when palpating for port

question

Implanted venous port requires

answer

Huber needle

question

Tunneled CVAD

answer

has single double, triple lumens

question

MCL line

answer

usually shorter than PICC line

question

Percutaneous CVAD

answer

inserted directly through skin into large vein

question

The percutaneous central venous catheter has less risk of developing an infection than the tunneled CVAD.

answer

A percutaneous central venous catheter is inserted directly through the skin into a large vein. Because the distance between the end of the catheter and the vein is short, there is a high risk of infection.

question

Heparin flush in the port is used when and why

answer

when continuous infusion is not indicated. It is used o prevent thrombus formation at the catheter tip

question

What is purpose of heparin flush regarding care of Central vascular access device?

answer

reduces incidence of clot formation at catheter tip

question

An implanted infusion port may have a single- or double subcutaneous injection port.

answer

No

question

Blood samples may be obtained from CVADs and implanted infusion ports.

answer

true

question

Complications of vascular access devices include infection and occlusion.

answer

true

question

Taking blood pressure or drawing blood should be avoided in the arm where a PICC or MCL line is located.

answer

You should avoid taking a blood pressure or obtaining a blood sample from the arm in which a PICC or MCL line is inserted, as pressure will temporarily occlude blood flow.

question

characteristics of a tunneled CVAD

answer

inserted through subQ between clavicle and nipple threaded into surer vena cava, lower risk of infection than non tunneled CVAD,held in place with dacron cuff, surgical procedure, nth tip lies in superior vena cava, may be single double or triple

question

Uses of CVAD device

answer

Iv fluids, blood samples, blood products, meds, parenteral nutrition, chemotherapy.

question

Categories of meds safest for pregnancy

answer

A ; B

question

Example of medicine cat. X

answer

Acutane

question

Example of medication cat. d

answer

Tetracycline

question

Route of admin for injections include

answer

subq, IM, ID, IV

question

The use of alcohol swabs and cleaning

answer

infection control use circular motion .

question

Injections

answer

pathway by which a drug comes into contact with the body

question

Ampules

answer

glass genie like bottles to which you break open away from you using alcohol swab package. Come in single use 1-10 ml. use filter needle to keep glass out of meds.

question

Why should you always tap ampule prior to breaking?

answer

It ensures all the med is at bottom of ampule

question

Vials

answer

come in single or multi dose, have rubber stopper that should always be wiped off to maintain sterility.

question

Reconstituted powder vials should include

answer

Date, time opened, medication,diluent and concentration, initials.

question

Multidose vials should include the following info after use to prevent contamination

answer

Date, Time and initials on vials when opened. Can be used for up to 30 days swab top w/ alcohol always,

question

Prevention of needle contamination include the following

answer

avoid letting needle touch contaminated surfaces outer edges of ampule, or vial outer surface of needle cap, your hands, countertop, table surface. Never touch the length of the plunger or inner part of barrel. Always keep tip of syringe covered with cap or needle

question

Infection control measures also include the following

answer

maintaining aspect technique by wash hands, wear gloves, cleaning site with alcohol or chlrohexidine

question

Always allow alcohol

answer

to dry completely

question

How do you prepare the skin for injection to prevent infection.

answer

1st: wash skin soiled with dirt, drainage, feces, with soap and water using friction and circular motion while cleaning with antiseptic swab. Swab from center of site using circular motion move out ward an inch radius

question

Size of needle is determined by which factors

answer

size of patient. tissue to be injected in, type of medication, age of patient. how much medicine is being admin.

question

Gauge of needles are determined by

answer

site of injection as well as viscosity of meds. Gauges are the smaller the gauge the larger the whole

question

Parts of syringe include.

answer

the tip (where needle goes), the barrel (measured/marked chamber), plunger

question

Always maintain sterility by not touching

answer

needle, tip, plunger

question

How to accurately measure meds is to

answer

line up middle ring of plunger where it touches the barrel with the correct line measured dose

question

Obese adults get injections at what angle?

answer

90 degree

question

Before giving a patient an injection, the nurse changes needles why?

answer

provides sharper needle with less pain, keeps meds from tracking through tissues.

question

After giving a subcutaneous injection of heparin, the nurse refrains from massaging the site to prevent?

answer

Tissue damage

question

Needle stick precautions state

answer

Use needless system or safety devices.Don't recap needle they are contaminated. Engage safety device & dispose of used needles in sharps after use. Always report sharp related injuries

question

You should NEVER EVER

answer

recap used needles

question

Clean & unused you may

answer

scoop up recap

question

Needles are color coded

answer

Blue 22, pink 20, green 18, yellow 24

question

Always inject with needle pointed

answer

bevel up

question

Needle selection includes

answer

length in inches which can be determined by route, size of patient and location.

question

Needle parts

answer

bevel, shaft, gauge, & hub

question

ID

answer

3/8 inch needle. Gauge can be 25-27 hold up to 0.1-0.3 ml & used for TB and allergy testing. Bleb will appear if bleb doesn't appear or bleeds it went in t sleep could go into anaphylactic shock

question

ID injection angle

answer

15 degrees. Do not scratch the site or rub

question

why should the nurse avoid massaging interdermal site?

answer

because it will disperse medication into underlying tissues.

question

sub Q

answer

loose connective tissue slower than IM gauges 25-26;3/8-5/8 in needle holds 0.1-1ml of medicine. pinch skin insert needle ,administer meds ; let go

question

Sub Q areas

answer

Scapular, deltoid, lovehandles, and vastus lateralis, belly. Avoid scars, lesions and dirty areas

question

Sub Q angle of needle

answer

45 to 90 degree angle. If you can pinch 2 in god in at 90 degree angle. 1 inch at a 45 angle.

question

SubQ meds

answer

Insulin rotate sites, Lovenox = love handles, popgun, anthrax vax

question

IM

answer

deep muscle faster infusion rate. Hold skin taught ; once needle is in skin use non dominant hand to hold needle pirate for blood return; if no blood noted inject slow. 1-1.5 in needles with gauges being 22-23 inches.20-21 hormones (thick viscous) Deltoid only can have 1 ml of med. other areas more unusual for more than 3. up to 5 depending on med.

question

Which of the following accurately describes hoe to local the ventrogluteal site?

answer

Place heel of hand over the greater trochanter, thumb towards patients groin,index fingers pointed towards the anterior superior iliac spine, middle fingers extend along the iliac crest

question

Should aspirate when admin IM... why?

answer

Yes because we don't want to see blood return. If blood presents, do not proceed. Med could get into blood stream causing bad reaction. Get blood start over.

question

Z track needle should be removed

answer

before skin is released to provide z track

question

Slow injection rate reduces?

answer

Pain and tissue trauma

question

ZTrack method

answer

releasing the tissues seals the needle track

question

IM sites

answer

Deltoid only 1ml, ventrogluteal preferred site, vastus lateralis (babies vaccine sites)

question

We no longer give IM meds where?

answer

Dorsogluteal, because it is not effective

question

Types of IM meds include

answer

Antibiotics, antihistamine, vaccines

question

Promethazine

answer

pushed to fast dilute or patient could loose fingers. always watch patient for reactions. If patient complains of burning stop admin and flush. Iv if infiltrated could cause bad reaction

question

6 rights of med admin.

answer

right patient, right medicine, right dosage, right route, right time, right documentation.

question

some other rights of med

answer

right dilution, speed of infusion,right to refuse

question

Always do this with med admin follow up after admin of meds.

answer

check med with EMAR twice if insulin or heparin have another check dosage with you once drawn up, check for allergies and to see if meds are compatible with Iv fluids; also check again before aspirating out of vial,check 2 patient id, double check again at bedside. follow up stay for the first ten minutes.

question

why is it important to inject air into vial?

answer

It prevents build up of negative pressure in the vial.

question

peripheral access devices

answer

winged butterfly needle, short, over-the-needle- catheter, midline peripheral

question

short, over-the-needle- catheter

answer

continuous intermittent infusion; short term duration

question

midline peripheral catheter

answer

continuous & intermittent use up to 1-4 weeks

question

winged butterfly IV catheter

answer

Infants requiring fluid maintenance. one time IV infusion; IV push add w/pH of 5-9

question

IV patients 18 gauge (green)

answer

Trauma; blood transfusion; surgery. Adults scheduled for major surgery

question

IV patients with 20 gauge (pink)

answer

continous or intermittent; blood transfusions. Young adults requiring fluid maintenance

question

IV patients with 22 gauge (blue)

answer

continous or intermittent infusions; children and elderly patients. Admin of blood or blood products in peds & negates. Older adult requiring IV medications.

question

IV patients with 24 (yellow)

answer

fragile veins for intermittent or continuous infusions; admin of blood or blood products in peds & neonates

question

larger gauges are good for what pH of meds

answer

acidic meds like Vancomycin and other antibiotics

question

IV sites nursing considerations

answer

Don't use o

question

Isotonic

answer

D5W, LR, 0.9% NS

question

the only fluids that can change with blood

answer

0.9% NS which is isotonic

question

Which isotonic fluid is used in critical situations?

answer

0.9% NS

question

Isotonic is used for

answer

vomiting ; diarrhea

question

Isotonic contradictions in patients

answer

could cause increase fluid in renal patients or cardiac

question

Hypotonic solutions

answer

0.45% NS or 1/2NS, 0.33% NS or 1/3 NS

question

hypotonic fluids do what?

answer

Dilute extracellular fluid and rehydrate cells could exacerbate hypotentensive states in low BP. Will swell normal cells

question

hypotonic

answer

Osmolality is less than outside. Moves osmosis into the cell. If normal swells the cell up

question

Hypertonic

answer

D10W, D50W, D51/2NS or D50.9%NS, D5LR, 3%-5% NS

question

hypertonic fluid are treated for what situations?

answer

Water intoxication. shifts fluid from ICF to ECF to vascular space to increase blood volume.

question

The nurse knows to never push which fluid?

answer

KCL or potassium chloride. direct push could be fatal, because hyperkalemia will quickly develop

question

What should the nurse verify before admin of KCL?

answer

Adequate U/O. serum levels of K+ to ensure it i below limits. Because hyperkalemia could quickly develop.

question

IV fluids should be checked prior for the following?

answer

Clarity, color, and expiration date

question

Procedure for preparing solution prior to initiating an IV is?

answer

Open infusion set, places roller clamp 2-5cm below drip chamber and moves roller clamp to off. Nurse removes protective sheath over the IV tubing port on IV bag, removes sheath of insertion spike and inserts spike into the bag Fill drip chamber 1/3 to 1/2 full, primes tubing making sure there are no air bubbles

question

The nurse preparing solution prior to initiating IV therapy and she touches the spike accidentally. What is the best nursing action at this time?

answer

Discard contaminated tubing and get a new tubing set

question

IV helpful hints.

answer

Let chlorhexidine dry thoroughly (it burns). If hairy you may clip hair (not shave). Don't stick more than twice if needle comes out get another. Pull skin tight bevel up.

question

Standards to decrease IV infection

answer

Palpate site throughout the day for tenderness and redness. Inspect catheter site if patient develops tenderness, fever w/out obvious source ,or symptoms of local or blood stream infection. perform hand hygiene before and after palpating, inserting or replacing, or dressing. clan skin with chlorohexidine before venipuncture allow to dry thoroughly.DO NOT PALPATE SKIN AFTER CLEANING

question

When should you replace dressing over catheter?

answer

when replacing catheter or when dressing becomes damp, loosened, or soiled.

question

How often to change gauze dressings that cover IV site?

answer

very 48 hours unless soiled do it sooner.

question

How long can IV tubing remain sterile

answer

96 hours

question

How often should you clean injection ports

answer

before they are accessed every single time

question

Documenting IV or pass on report should include

answer

time, date, intials on IV dressing. document time date, initials, catheter size used, number of sticks, type of fluid, flow rate,patients response (tolerated or not). Was it a difficult stick. document that as well. potency of IV, date IV started, amount left in bag

question

Iv sites for adults

answer

Dorsal and ventral surface of arms (basilic & cephalic & median) avoid lateral surface of the wrist. Use most distill site in non dominant arm if possible.

question

Tourniquet placement should be how many inches?

answer

4-6 inches above the antecubital fossa. In elderly you may use a blood pressure cuff.

question

When should the tourniquet be released a second time?

answer

After flashback of blood return has been observed and catheter has been advanced off the stylet

question

where would you move iv site if there were no complications?

answer

Proximal site from previous

question

What angle should Iv puncture vein?

answer

10-30 degree angle

question

Which of the following should be avoided for IV insertion?

answer

Foot of an adult because of thrombophlebitis risk, inner wrist because of tendons and nerves, distal site from previous site because increased risk of infiltrating new IV line, areas of venous burfication, shunt sites, left mastectomy side, side of paralysis, sclerosed cordlike veins,

question

In children and older adults which IV site should be avoided?

answer

dorsal surface of hand because its fragile and early bumped

question

Methods to improve venous distention

answer

Warm pack on extremity & stroking from distal to proximal below site never tap

question

Avoid vein selection in

answer

Areas red tenderness, lesions, scars , pain or infection. extremity involved in CVA, shunts, and vasectomy site distal from last venous puncture go proximal instead, avoid venous valves, infiltrated sites

question

phlebitis

answer

red, tenderness, edema along track of vein. in CVAD appears 7-10 days after insertion.stages 1-4 . 1 red watch site, 2 red tenderness streaking. 3 streaking slight chord felt, 4 feels chord hard red tender move IV

question

infiltration

answer

cool to touch,spongy pallor, swollen, may need antidote if its a bad med.

question

Tegaderm should be placed

answer

so that the colored portion hub of Iv tubing can be accessed to disconnect

question

IV tubing must be changed

answer

every 96 hours

question

Iv site needs to be moved or rotated

answer

every 96 hours

question

How often to change IV fluid bag

answer

every 24 hours or sooner based on infusion rate.

question

How much fluid should be left before changing bags.

answer

Bags should never empty completely. Always set alarm for 50 cc to remain

question

Micro drip rate

answer

used often infants. easy to calculate rate times hourly by 1. there is our drip rate. Lo

question

Clinical markers of volume include

answer

I/O, vital signs, dissented neck veins, edema, cap refill, auscutaion of lungs

question

Fluid excess clinical manifestations include

answer

Hypetensive, crackles in lungs, peripheral edema, dissented neck veins,

question

Fluid deficits include

answer

Hypotensive state, dry lips, low I/O, flat veins hard to stick temp increases, tenting of skin, hyperanetremia, sluggish cap refill

question

When hanging blood products the nurse must.

answer

Use new tubing every time.

question

Every two hours the nurse must check and verify

answer

The IV site is w/out tenderness edema, redness, and inflammation pus, wetness, bleeding.

question

A saline lock should be flushed

answer

Every time it is used (before and after) Flush every eight hours.

question

Saline lock, heparin lock, IV plug, or adapter are

answer

Extension sets with needless adapter

question

Iv site is tender to palpation with an area of erythema the nurse must

answer

Stop infusion, discontinue IV, notify HCP, start new IV if continued therapy is needed, place moist warm compress

question

Poor skin turgor, concentrated urine, dry mucous membranes

answer

Notify HCP, this may require readjustment of infusion rate

question

Crackles over mid & lower lobes

answer

Reduce iv fluids, notify HCP, likely from fluid excess

question

Abnormal serum electrolytes

answer

Notify HCP, may need order for additives IV or change in fluids

question

IV site cool to touch, swelling, tenderness at site

answer

Stop infusion, discontinue IV, elevate effected extremity, restart newIV if continued therapy is necessary

question

Rotating IV sites every 96 hours prevents

answer

Phlebitis

question

Avoid IV running dry prevents

answer

Occlusion

question

Use of volume control devices, Volutrol prevents

answer

Fluid volume access

question

Maintains strict asepsis prevents

answer

Infection

question

Why is it important to discontinue IV site if phlebitis is evident?

answer

Phlebitis is dangerous and blood clots can occur and may result in emboli. which may result in permanent damage

question

The nurse notices failure of flow in the drip chamber w/ the roller clamp open and an absence of swelling the insertion site. What should the nurse do?

answer

Determine for potency by aspirating for blood return & check for kinking

question

Situations in which a indicative of discontinuation of peripheral IV access

answer

Pt is being discharged home on PO meds. The EIpump alarm s sounding indicating occlusion and the nurse is unable to flush. The patients arm is swollen & cool to touch & is complaining of pain at IV site Pt arm red and tender to touch. IV site is dated 4 days ago

question

Always inspect catheter after removal for intactness, if not intact the nurse must

answer

ER situation, must contact HCP immediately can cause embolus

question

Primary danger of broken catheter tip is?

answer

Embolus

question

Hematoma formation

answer

apply pressure dressing to site

question

Site is reddened and tender

answer

Discontinue site, Notify HCP,May apply warm moist pack

question

Catheter tipis broken off

answer

Notify HCP immediately, ER situation

question

discontinuation of Iv should include

answer

time ,date, gauge & size of needleof IV, catheter tip intact

Fundamentals of Nursing Exam IV TTU – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards