Mosby – IV – Administering IV Fluid Therapy – Flashcards
Unlock all answers in this set
Unlock answersquestion
what cannot be delegated
answer
- The skill of initiating intravenous therapy may not be delegated - The skill of caring for an intravenous site may not be delegated - The skill of troubleshooting intravenous infusions may not be delegated - The skill of discontinuing a short peripheral intravenous line may not be delegated
question
Instruct NAP to notify you if
answer
- the dressing becomes wet or if the patient complains of any IV-related complications, such as pain, redness, swelling, or bleeding. - the patient's IV dressing becomes wet. - the level of fluid in the IV bag is low or the electronic infusion device (EID) alarm sounds. - any bleeding at the site after the catheter has been removed - any complaints of pain by the patient or observations of redness at the site.
question
Do not palpate or touch the insertion site after ________.
answer
the skin has been cleansed
question
Use ______ gloves during all aspects of IV care.
answer
clean
question
Do not rub or repeatedly or vigorously tap a vein, especially in an older adult, since doing so can ______.
answer
cause hematoma formation and/or venous constriction
question
Avoid using the superficial dorsal veins because of the ________.
answer
risk for infiltration due to movement
question
Because of the risk for nerve damage, avoid using the veins on the _______ of the wrist.
answer
thumb side and palmar side
question
For comfort and mobility, place the IV in the ______ arm.
answer
nondominant
question
If hair removal is needed, do not shave the area with a razor, which may cause microabrasions that increase the risk for infection. Instead, ________.
answer
clip the hair with scissors
question
Veins on the dorsal and ventral surfaces of the arms, such as the _______, are preferred in adults.
answer
cephalic, basilic, or median
question
Avoid vein selection in:
answer
(1) Areas with tenderness, redness, rash, pain, or infection (2) An extremity affected by previous cerebrovascular accident (CVA), paralysis, dialysis shunt, or mastectomy (3) Any site distal to a previous venipuncture site, sclerosed or hardened veins, a site of infiltrate, areas of venous valves, or phlebitic vessels (4) Fragile dorsal hand veins in older adults
question
Apply a tourniquet (or blood pressure cuff) around the patient's arm ______ above the proposed insertion site.
answer
10 to 15 cm (4 to 6 inches)
question
Select a vein large enough for VAD insertion:
answer
A. Use the most distal site in the nondominant arm if possible. B. Select a well-dilated vein.
question
1. Which technique is most accurate in identifying an appropriate vein site for IV catheter insertion into the arm? Remove any clothing that is covering the arm. Apply a warm washcloth to the arm at the proposed site. Elevate the selected arm on a pillow for 2 to 3 minutes. Apply a tourniquet to the selected arm 4 to 6 inches above the proposed site.
answer
Remove any clothing that is covering the arm. Apply a warm washcloth to the arm at the proposed site. Elevate the selected arm on a pillow for 2 to 3 minutes. *Apply a tourniquet to the selected arm 4 to 6 inches above the proposed site.* CORRECT. Applying a tourniquet will distend the vein, making the intended insertion point more visible and allowing the nurse to determine if the vein can accommodate the IV catheter.
question
2. When preparing to insert a venous access device, how can the nurse encourage patient compliance with the procedure? Assess the patient's understanding of the placement of the device. Insert the access device as quickly as possible. Ask the patient to select the arm preferred for access. Apply a topical anesthetic to the area before inserting the device.
answer
*Assess the patient's understanding of the placement of the device.* Insert the access device as quickly as possible. Ask the patient to select the arm preferred for access. Apply a topical anesthetic to the area before inserting the device. CORRECT. The nurse would assess the patient's understanding of device placement before inserting the device. Doing so would increase patient compliance with the procedure.
question
3. Which action minimizes the patient's risk for injury when inserting a venous access device into the arm? Wearing clean gloves during the procedure Using a larger vein found on the palmar (ventral) side of the wrist Checking for a radial pulse once the tourniquet has been applied Priming the extension tubing after attaching it to the newly placed venous access device
answer
Wearing clean gloves during the procedure Using a larger vein found on the palmar (ventral) side of the wrist *Checking for a radial pulse once the tourniquet has been applied* Priming the extension tubing after attaching it to the newly placed venous access device CORRECT. Assessing for a radial pulse after the tourniquet is in place ensures that circulation to the distal extremity has not been compromised.
question
4. The nurse is preparing to insert a venous access device into a newly admitted 75-year-old patient. Which vein is not an appropriate choice for IV insertion in this patient? Basilic vein Cephalic vein Superficial dorsal vein Median cubital vein
answer
Basilic vein Cephalic vein *Superficial dorsal vein* Median cubital vein CORRECT. Superficial veins located on the dorsal surface of the hand must be avoided because of the risk for infiltration due to excessive movement. They are also more fragile in older adults.
question
5. The nurse is using chlorhexidine to prepare the site before inserting a venous access device into the median cubital vein of a 60-year-old patient. Which action is correct? Wash the site with soap and water. Allow the site to dry 1 to 2 minutes after cleansing it with chlorhexidine. Cleanse the site using a circular motion, starting at the insertion site and working outward. Cleanse the area by first swabbing horizontally, then vertically with the applicator for about 30 seconds.
answer
Wash the site with soap and water. Allow the site to dry 1 to 2 minutes after cleansing it with chlorhexidine. Cleanse the site using a circular motion, starting at the insertion site and working outward. *Cleanse the area by first swabbing horizontally, then vertically with the applicator for about 30 seconds.* CORRECT. Chlorhexidine thoroughly cleanses the skin when first horizontal and then vertical swabbing is performed for 30 seconds.
question
A single nurse should not make more than ______ at initiating IV access. After ____ attempts, the nurse should have another nurse attempt the insertion.
answer
two attempts
question
Assess for clinical factors/conditions that will respond to or be affected by administration of IV solutions:
answer
Body weight Clinical markers of vascular volume Clinical markers of interstitial volume Thirst Behavior and level of consciousness
question
After swabbing the insertion site briskly in a_______ pattern, perform venipuncture.
answer
horizontal, then vertical, then circular
question
Anchor the vein below the site by placing your thumb over the vein and gently stretching the skin against the direction of the insertion _______ distal to the site. Ask the patient to relax his hand.
answer
4 to 5 cm (l to 2 inches)
question
Insert the vascular access device with the bevel up at a _____ degree angle slightly distal to the actual site of venipuncture in the direction of the vein.
answer
10 to 30
question
Observe for blood return through the ______, indicating that the bevel of the needle has entered the vein.
answer
flashback chamber of the catheter
question
Observe the patient every 1 to 2 hours after administering an IV or at established intervals per your agency's policies and procedures for the following:
answer
- Verify the type/amount of IV solution that has infused by observing the fluid level in the IV container. - Check the infusion rate on the EID, or count the drip rate (if the solution is infusing by gravity). - Check the patency of the vascular access device. - Observe the patient for signs of discomfort during palpation of the vessel (over the transparent semipermeable membrane [TSM] dressing). - Inspect the insertion site, noting its color, such as redness or pallor. - Inspect the site for the presence of swelling, which is a sign of infiltration, or pain and tenderness, which is a sign of phlebitis. Feel the temperature of the patient's skin above the dressing.
question
under documentation for IV, we would record:
answer
- number of attempts and sites - precisely describing the insertion site, such as "cephalic vein on dorsal surface of right lower arm, 2.5 cm [1 inch] above wrist." - the method of infusion (gravity or electronic infusion device); type and rate of infusion; device identification number (if you are using an electronic infusion device); size, length, and brand of catheter; when the infusion began; and the patient's response to the insertion. Use an infusion therapy flowsheet when available.
question
when changing to oncoming nursing staff, what info about an IV should be reported?
answer
the type of fluid, flow rate, status of the vascular access device, amount of solution remaining in the infusion bag, expected time for completion of infusion and need to hang subsequent IV containers, and the patient's condition.
question
Report to the ________ any signs and symptoms of IV-related complications.
answer
health care provider
question
1. Which action would the nurse perform to best ensure effective insertion of a venous access device into a patient's arm? Anchor the vein by placing a thumb 1 to 2 inches below the site. Insert the device tip at a 45-degree angle distal to the proposed site. Place the patient's left arm in a dependent position for 5 minutes before assessment. Apply a tourniquet to the left antecubital fossa 8 to 12 inches above the proposed site.
answer
*Anchor the vein by placing a thumb 1 to 2 inches below the site.* Insert the device tip at a 45-degree angle distal to the proposed site. Place the patient's left arm in a dependent position for 5 minutes before assessment. Apply a tourniquet to the left antecubital fossa 8 to 12 inches above the proposed site. CORRECT. This action stabilizes the vein, increasing the possibility of a successful insertion.
question
2. How might the nurse prepare a patient to anticipate some discomfort when inserting a venous access device? Instruct the patient to expect a sharp, quick stick. Insert the access device as quickly as possible. Apply a topical anesthetic to the area before inserting the device. Promise that the procedure will not hurt once the device has been inserted.
answer
*Instruct the patient to expect a sharp, quick stick.* Insert the access device as quickly as possible. Apply a topical anesthetic to the area before inserting the device. Promise that the procedure will not hurt once the device has been inserted. CORRECT. Educating the patient to have reasonable expectations about the possible discomfort will best prepare him or her for it.
question
3. Which of the following technique(s) is/are best for minimizing a patient's risk for injury when inserting a venous access device? Inserting the needle with the bevel up Using a vein on the dorsal surface of the arm Holding the skin taut directly below the site All of the above
answer
Inserting the needle with the bevel up Using a vein on the dorsal surface of the arm Holding the skin taut directly below the site *All of the above* CORRECT. All of these actions will minimize injury to the patient.
question
4. The nurse is inserting an over-the-needle catheter into a newly admitted patient. What will the nurse do after confirming blood return? Loosen or remove the tourniquet. Advance the catheter 1 inch into the vein. Lower the catheter until it is flush with the skin. Thread the catheter into the vein up to the hub.
answer
Loosen or remove the tourniquet. Advance the catheter 1 inch into the vein. *Lower the catheter until it is flush with the skin.* Thread the catheter into the vein up to the hub. CORRECT. Lowering the catheter until it is flush with the skin minimizes the risk of passing the needle through the opposite vessel wall.
question
5. Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with an intravenous access device? "Assess the IV site frequently for signs of inflammation." "Be sure not to obscure the insertion site with the dressing." "Let me know when you notice that the IV bag contains less than 100 milliliters." "Explain the symptoms of infection to the patient."
answer
"Assess the IV site frequently for signs of inflammation." "Be sure not to obscure the insertion site with the dressing." * "Let me know when you notice that the IV bag contains less than 100 milliliters."* "Explain the symptoms of infection to the patient." CORRECT. The task of reporting when the level of fluid in the IV bag is low may be delegated to NAP.
question
____ the insertion site for tenderness every shift (or according to agency policy) through the intact dressing.
answer
Palpate
question
Directly inspect a catheter site if the patient develops _______.
answer
tenderness at the site, fever without an obvious source, or symptoms of local or bloodstream infection.
question
Gauze dressings that cover a catheter site must be changed every _______. Intravenous tubing administration sets can remain sterile for _____.
answer
48 hours 96 hours
question
Label the IV dressing according to your agency's policy. Include the ________
answer
date and time of the IV insertion, VAD (vascular access device) gauge and length, and your initials.
question
*watch the dressing the infusion site video* it will make more sense to view it.
answer
*watch the dressing the infusion site video*
question
for IV dressing changes, record:
answer
time of dressing change, reason for change, type of dressing material used, patency of system and description of venipuncture site.
question
1. Why is it important to label the gauze dressing covering the site of an intravenous access device with the date, time, and nurse's initials? Reminds the nurse to document the insertion of the device Proves that the access site was assessed Informs the nurse and other staff when the next dressing change is due Reminds the nurse when to change the infusion tubing
answer
Reminds the nurse to document the insertion of the device Proves that the access site was assessed *Informs the nurse and other staff when the next dressing change is due* Reminds the nurse when to change the infusion tubing CORRECT. The gauze dressing over an intravenous access site must be changed every 48 hours. This is the reason for labeling the dressing with the date, time, and nurse's initials.
question
2. Which action will the nurse take to minimize a patient's risk for injury when applying a dressing to an infusion site? Use aseptic technique throughout the process. Apply a skin protectant to the skin before the intervention. Apply a transparent dressing that allows for visualization of the site. Explain the process to the patient before implementation.
answer
*Use aseptic technique throughout the process.* Apply a skin protectant to the skin before the intervention. Apply a transparent dressing that allows for visualization of the site. Explain the process to the patient before implementation. CORRECT. Following aseptic technique throughout the dressing application will minimize the patient's risk for injury related to infection.
question
3. The nursing assistive personnel (NAP) reports to the nurse that a patient's intravenous access device dressing is wet. What would the nurse do first? Assess the site. Instruct the NAP on how to change the dressing. Remove the device, and insert a new one. Reinforce the dressing with more gauze.
answer
*Assess the site.* Instruct the NAP on how to change the dressing. Remove the device, and insert a new one. Reinforce the dressing with more gauze. CORRECT. The nurse would first assess the site to check for infiltration and to see if the IV has become dislodged.
question
4. When applying a dressing to an infusion site on a patient's left forearm, what will the nurse do to ensure proper maintenance of the tubing? Apply a transparent dressing to the insertion site. Use a catheter stabilizing device when applying the dressing. Apply the dressing proximal to the tubing and catheter hub connector. Secure the tubing to the patient's dressing with 1-inch tape.
answer
Apply a transparent dressing to the insertion site. Use a catheter stabilizing device when applying the dressing. * Apply the dressing proximal to the tubing and catheter hub connector.* Secure the tubing to the patient's dressing with 1-inch tape. CORRECT. Applying the dressing proximal to the tubing and catheter hub connector will allow the tubing to be disconnected and changed when indicated.
question
5. Which action will the nurse take to minimize a patient's risk for injury when applying a gauze dressing to an infusion site? Avoid encircling the arm with tape Not secure the tubing and catheter hub with tape Secure the tubing in two different locations on the arm Label the dressing with the date and time of application
answer
*Avoid encircling the arm with tape* Not secure the tubing and catheter hub with tape Secure the tubing in two different locations on the arm Label the dressing with the date and time of application CORRECT. The nurse will avoid encircling the arm with tape, because doing so can impede circulation in the arm.
question
To troubleshoot IV infusions, prepare by :
answer
determining the patient's level of comfort and the expected response to IV therapy. Assess the patient's vital signs, fluid status, and intake and output at least every 8 hours or according to agency policy, and more often if indicated.
question
To determine if the correct amount of IV solution has infused, _____.
answer
review the infusion pump record
question
If the volume of fluid that has been infused is less than that which should have been instilled by this time, check for possible causes. First, check the _____.
answer
flow rate on the infusion pump or count the drip rate If the infusion rate is set correctly but the pump is sounding the alarm for "occlusion", look for kinks in the tubing, which can occur if the patient lies on the tubing or if it becomes caught in a side rail. Make sure the entire length of the tubing is patent and intact.
question
If infusion rate and line is clear of occlusions, next check
answer
assess the IV device. The hub connecting the tube to the catheter should be intact, with no signs of leakage or bleeding
question
Bleeding may be caused by:
answer
A. Disconnection of the tubing from the IV device B. A bleeding disorder C. Anticoagulant therapy
question
Inspect the dressing, which should be _____ Also inspect the insertion site for _______.
answer
dry and intact color changes, swelling, and purulent drainage
question
Palpate along the vessel and around the inser tion site to detect venous cords. As you do so, note the skin temperature to be alert for signs of ________. If either of these is supected, stop the infusion and evaluate the severity of the problem.
answer
phlebitis and infiltration
question
If you detect any signs of phlebitis, use a phlebitis scale to grade the severity of the problem. A. ______ represents no signs or symptoms. B. Symptom severity increases up to a score of ____, which reflects pain, redness, and swelling at the site; streaking, which is a _______; and purulent drainage. For phlebitis or infiltration, stop the infusion and discontinue the IV.
answer
Zero four a palpable venous cord more than 1 inch (2.5 cm) long
question
Change the IV device every ____. Change it more frequently if ordered or if complications occur.
answer
72 hours
question
1. The nurse consistently observes that the positioning of a confused patient's arm has a direct effect on the flow rate of the intravenous (IV) solution. What might the nurse do to ensure infusion of the patient's IV fluid at a consistent rate? Restart the IV in another location less affected by the patient's positioning. Include this information in the shift report regarding this patient. Assess the flow rate every 1 to 2 hours. Instruct the patient to avoid positioning the arm in ways that alter the flow rate of the solution.
answer
*Restart the IV in another location less affected by the patient's positioning.* Include this information in the shift report regarding this patient. Assess the flow rate every 1 to 2 hours. Instruct the patient to avoid positioning the arm in ways that alter the flow rate of the solution. CORRECT. Restarting the IV in another location is the best option to ensure the effectiveness of the patient's IV therapy.
question
2. Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a venous access device? "Assess the IV site frequently for signs of inflammation." "Be sure not to obscure the insertion site with the dressing." "Let me know if you notice that the dressing has become damp." "Make sure the patient knows to notify me if the IV site becomes painful, swollen, or red."
answer
"Assess the IV site frequently for signs of inflammation." "Be sure not to obscure the insertion site with the dressing." * "Let me know if you notice that the dressing has become damp."* "Make sure the patient knows to notify me if the IV site becomes painful, swollen, or red." CORRECT. The task of reporting if a dressing becomes damp may be delegated to NAP.
question
3. What might the nurse do to minimize the risk for injury in a patient receiving IV therapy? Regulate the flow rate of the infusion. Assess the patient frequently for pain at the IV site. Monitor the IV site frequently for signs of infiltration and phlebitis. Educate the patient regarding symptoms of infiltration and phlebitis.
answer
* Regulate the flow rate of the infusion.* Assess the patient frequently for pain at the IV site. Monitor the IV site frequently for signs of infiltration and phlebitis. Educate the patient regarding symptoms of infiltration and phlebitis. CORRECT. Regulating the rate will minimize the risk for fluid overload.
question
4. The nurse observes erythema at the insertion site of a patient's IV infusion device. When asked, the patient denies pain at the site. Using the phlebitis scale, what score does the nurse give the injury? 1 2 3 4
answer
*1* 2 3 4 CORRECT. The nurse would give this injury a score of 1, which indicates redness at the access site with or without pain.
question
5. A patient's IV site has developed phlebitis scored as a 4 on the phlebitis scale. What would the nurse do to help treat the site? Apply a cool compress. Apply a warm compress. Apply a pressure dressing. Apply an elastic compression wrap.
answer
Apply a cool compress. *Apply a warm compress.* Apply a pressure dressing. Apply an elastic compression wrap. CORRECT. An IV site with evidence of phlebitis is to be wrapped with a warm compress.
question
Use caution to avoid breaking off the catheter during removal, since a damaged catheter increases the risk for _____.
answer
embolus formation
question
Never use scissors to remove the tape or dressing because you may accidentally _______.
answer
cut the catheter
question
1. What would the nurse do to assess a patient's risk for embolus when removing a venous access device? Inspect the site for redness. Visualize the tip of the IV device. Palpate the site for possible edema. Ask the patient to rate any pain at the site.
answer
Inspect the site for redness. * Visualize the tip of the IV device.* Palpate the site for possible edema. Ask the patient to rate any pain at the site. CORRECT. Damage to the tip of the device, resulting in a portion of the device remaining in the vessel, may cause an embolus to form.
question
2. Which instruction might the nurse give to nursing assistive personnel (NAP) when caring for a patient whose IV access device is to be removed? "Remember to wear gloves to minimize the risk for infection." "Be sure to keep pressure on the site for at least 2 to 3 minutes." "Let me know if you notice any bleeding on the site dressing." "Make sure the patient knows to notify me if the IV site becomes painful."
answer
"Remember to wear gloves to minimize the risk for infection." "Be sure to keep pressure on the site for at least 2 to 3 minutes." * "Let me know if you notice any bleeding on the site dressing."* "Make sure the patient knows to notify me if the IV site becomes painful." CORRECT. The nurse might offer this instruction because the task of reporting signs of bleeding may be delegated to NAP.
question
3. What might the nurse do to improve a patient's cooperation during the removal of an IV access device? Describe the entire procedure to the patient. Assure the patient that you will remove the IV catheter quickly. Assure the patient that the procedure will take only about 5 minutes. Tell the patient that the procedure will cause only a slight burning sensation.
answer
*Describe the entire procedure to the patient.* Assure the patient that you will remove the IV catheter quickly. Assure the patient that the procedure will take only about 5 minutes. Tell the patient that the procedure will cause only a slight burning sensation. CORRECT. Describing the entire procedure in advance will minimize fear and thus encourage the patient's cooperation.
question
4. Which action will best minimize the patient's risk for vein injury when removing an IV access device from a patient's arm? Keep the hub parallel to the skin. Cleanse the site with an antibacterial swab. Cut the dressing to facilitate its removal. Turn the IV tubing roller clamp to the "off" position.
answer
* Keep the hub parallel to the skin.* Cleanse the site with an antibacterial swab. Cut the dressing to facilitate its removal. Turn the IV tubing roller clamp to the "off" position. CORRECT. Keeping the hub parallel to the skin minimizes vein trauma during removal of the device.
question
5. What will the nurse do to prevent possible complications after removing an IV access device in a patient on anticoagulant therapy? Instruct the patient to report immediately any sign of bleeding on the site dressing. Perform hand hygiene and wear clean gloves while removing the device. Encourage the patient to keep a cold compress on the site for 15 minutes. Apply firm pressure to the site with sterile gauze for 10 minutes.
answer
Instruct the patient to report immediately any sign of bleeding on the site dressing. Perform hand hygiene and wear clean gloves while removing the device. Encourage the patient to keep a cold compress on the site for 15 minutes. *Apply firm pressure to the site with sterile gauze for 10 minutes.* CORRECT. Applying firm pressure will facilitate clotting. Maintaining pressure at the site for 5 to 10 minutes is recommended because the patient is receiving medication that prolongs the amount of time it takes for blood to clot.
