Saunders Intravenous Therapy RN Nclex, Exams of Nursing

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Saunders Intravenous Therapy RN

Nclex

Adult Health II (Hillsborough

Community College)

CHAPTER 13 Intravenous Therapy 145

TABLE 13-1 Types of Intravenous Solutions

Solution and Type Uses

0.9% saline (NS): Isotonic Extracellular fluid deficits in clients with low serum levels of sodium or chloride and metabolic acid-base imbalances. Used before or after the infusion of blood products.

Ringer’s lactate solution: Isotonic Extracellular fluid deficits, such as fluid loss from burns, bleeding, and dehydration from loss of bile or diarrhea.

5% dextrose in water (D 5 W): Isotonic at the time of administration; within a short time after administration, dextrose is metabolized and the tonicity decreases in proportion to the osmolarity or tonicity of the nondextrose components (electrolytes) within the water (may become hypotonic).

5% dextrose in 0.225% saline (5% D/ 1/ 4 NS): Isotonic at the time of administration; within a short time after administration, dextrose is metabolized and the tonicity decreases in proportion to the osmolarityor tonicity of the nondextrose components (electrolytes) within the water (may become hypertonic).

Replaces deficits of total body water. Not used alone to expand extracellular fluid volume because dilution of electrolytes can occur.

Used as initial fluid for hydration because it provides more water than sodium. Commonly used as maintenance fluid.

5% dextrose in 0.9% saline (5% D/ NS): Hypertonic Extracellular fluid deficits in clients with low serum levels of sodium or chloride and metabolic alkalosis.

5% dextrose in 0.45% saline (5% D/ 1/ 2 NS): Hypertonic Used as initial fluid for hydration because it provided more water than sodium. Commonly used as maintenance fluid.

5% dextrose in Ringer’s lactate solution: Hypertonic Extracellular fluid deficits, such as fluid loss from burns, bleeding, and dehydration from loss of bile or diarrhea.

3. Th e size of the gauge used dep ends on the solu- tion to be administered and the

diameter of the available vein.

4. Large-diam eter lu mens (smaller gauge nu mb ers) allow a higher fluid rate than

smaller diameter lu mens and allow the administration of higher con cen trations of solutions.

5. For rapid emergency fluid administration, blood products, or anesthetics,

preoperative and post- operative clients, large-diameter lumen needles or cannulas are used, such as an 18- or 19-gauge lumen or cannula.

6. For peripheral fat emulsion (lipids) infusions, a 20- or 21-gauge lumen or cannula is

used.

7. For standard IV fluid and clear liquid IV medica- tions, a 22- or 24-gauge lumen or

cannula is used.

8. If the client has very small veins, a 24- to 25- gauge lumen or cannula is used.

Spike end for IV bag or bottle

Drip chamber

Roller cla mp

Y s ite

Ada pter end of tubing to needle

C. IV containers

1. Container may be glass or plastic.

2. Squeeze the plastic bag to ensure intactness and assess the glass bottle for anycracks before

hanging.

3. Recon stitute any medications per agency proto- col and pharmacy instruction.

Do not write on a plastic IV bag with a marking pen because the ink may be absorbed through the plastic into the solution. Use a label and a ballpoint pen for writ- ing on the label, placing the label onto the bag.

D. IV tubing (Fig. 13-1)

1. IVtubing contains a spike end for the bag or bot- tle, drip chamber, roller clamp, Y

site, and adapter end for attachment to the cannula or needle that is in serted into the client’s vein.

FIGURE 13-1 Intravenous (IV) tubing.

2. Sh orter, secondary tubing is used for piggyback solution s, connecting them to the

injection sites nearest to the drip chamber (Fig. 13-2 ).

3. Special tubing is used for medication that absorbs into plastic (check specific

medication administration guidelines when administering IV medications).

4. Vented and nonvented tubing are available.

a. A vent allows air to enter the IV container as the fluid leaves.

b. A vented adapter can be used to add a vent to a nonvented IV tubing system.

c. Use nonvented tubing for flexible containers.

CHAPTER 13 Intravenous Therapy 147

a. A device that allows the client to self- administer IV medication, such as an

analge- sic; the client can administer doses at set inter- vals and the p u mp can be set to lock out doses that are not within the preset time frame to prevent overdose.

b. Th e PCA regimen may include a basal rate of infusion along with the dema n d

dosing, basal rate infusion alone, or dema nd dosing alone.

c. A bolus dose can be given prior to any of the settin gs and should be set based on

the HCP’s prescription.

d. PCAs are always kept locked and setup requires the witness of another registered

nurse (RN).

Check electronic IV infusion devices frequently. Although these devices are electronic, this does not ensure that they are infusing solutions and medications accurately.

III. Latex Allergy

A. Assess the client for an allergy to latex.

B. IV supplies, including IV catheters, IV tubing, IV ports (particularly IV rubber injection

ports), rubber stoppers on multidose vials, and adhesive tape, may con tain latex.

C. Latex-safe IVsupplies need to be used for clients with

a latex allergy; most agencies carry these now, but this still needs to be checked.

D. See Chapter 66 for additional information regarding

latex allergy.

IV. Selection of a Peripheral IV Site

A. Veins in the ha n d, forearm, and antecubital fossa are suitable sites (Fig. 13-4 ).

B. Veins in the lower extremities (legs and feet) are not

suitable for an adult clien t because ofthe risk ofthrom- bus formation and the possible pooling of medication in areas of decreased venous return (Box 13-1 ).

C. Veins in the scalp and feet may be suitable sites for

infants.

Basilic vein Cephalic

D. Assess the veins of both arms closely before selecting a site.

E. Start the IV infusion distally to provide the option of proceedin g up the extremity if the vein is

ruptured o r infiltration occurs; if infiltration occurs from the ante- cubital vein, the lower veins in the same arm usually should not be used for further puncture sites.

F. Determine the client’s d o mi na nt side, and select the

opposite side for a venipuncture site.

G. Ben ding the elbow on the arm with an IV ma y easily obstruct the flow of solution, causing

infiltration that could lead to thromb ophlebitis.

H. Avoid checking the blood pressure on the arm receiv-

ing the IV infusion if possible.

I. Do not place restraints over the venipuncture site.

J. Use an armboard as needed when the venipuncture site is located in an area of flexion.

In an adult, the most frequentlyused sites for insert- ing an IV cannula or needle are the veins of the forearm because the bones of the forearm act as a natural sup- port and splint.

V. Initiation and Administration of IV Solutions

A. Check the IVsolution against the HCP’s prescription for the type, amount, percentage of solution,

and rate of flow; follow the 6 rights for medication administration.

B. Assess the health status and medical disorders of the

clien t and identify clien t con ditions that con traindi- cate use of a particular IV solution or IV equ ip ment, such as an allergy to clean sin g solution , adhesive materials, or latex. Check compatibility of IV solu- tions as appropriate.

C. Check client’s identification and explain the proce-

dure to the client; assess client’s previous experience

vein

Cephalic ve in

Radial ve in

A

Me dian cubita l vein

Me dian vein of fore arm

Basilic ve in

Cephalic ve in B

Superficial dorsal veins

Dorsal ve nous arch

Basilic vein

with IV therapy and preference for insertion site.

D. Wash ha nds thoroughly before inserting an IV line and before working with an IV line;

wear gloves.

E. Use sterile techniqu e when inserting an IV line and

when changing the dressing over the IV site.

F. Change the venipuncture site every 72 to 96 hours in accordan ce with Centers for Disease

Control and Pre- vention (CDC) recommendations and agency policy.

G. Change the IV dressing when the dressing is wet or

contaminated, or as specified by the agency policy.

H. Change the IV tubing every 96 hours in accordance

FIGURE 13-4 Common intravenous sites. A, Inner arm. B, Dorsal surface of hand. with CDC recommendat ions and agency policy or^ with change of venipuncture site.

BOX 13 - 1 Peripheral Intravenous Sites to Avoid

▪

▪

▪

▪

▪

Edematous extremity

An arm that is weak, traumatized, or paralyzed

The arm on the same side as a mastectomy

An arm that has an arteriovenous fistula or shunt for

dialysis

A skin area that is infected

148 UNIT III Nursing Sciences

I. Do n ot let an IV bag or bottle of solution ha ng for more than 24 hours to diminish the

potential for bacterial contamination and possibly sepsis.

J. Do not allow the IVtubing to touch the floor to pre-

vent potential bacterial contamination.

K. See Priority Nursing Actions for instructions on inserting an IV.

L. See Priority Nursing Actions for instructions on

removing an IV.

PRIORITYNURSING ACTIONS

Inserting a Peripheral Intravenous Line

1. Check the health care provider’s (HCP’s) prescription, determine the type and size of infusion

device, and prepare intravenous (IV) tubing or extension set and solution; prime IV tubing or extension set to remove air from the system; explain procedure to the client.

2. Select the vein for insertion based on vein quality, client size, and indication of IV therapy; apply

tourniquet and pal- pate the vein for resilience (see Fig. 13-4).

3. Clean the skin with an antimicrobialsolution, using an inner to outercircularmotion, oras specified

bythe Centers for Disease Control and Prevention (CDC) guidelines and agency policy.

4. Stabilize the vein below the insertion site and puncture the skin and vein, observing for blood in the

flashback chamber; when observed, lower the catheter so that it is flush with the skin and advance the catheter into the vein (ifunsuccessful, a new sterile device is used for the next attempt at insertion).

5. Remove the tourniquet. Apply pressure above the insertion site with the middle finger of the

nondominant hand and retract the stylet from the catheter; connect the end of the IV tubing or extension set to the catheter tubing, secure it, and begin IVflow. Ask the client about comfort at the site and assess site for adequate flow.

6. Tape and secure insertion site with a transparent dressing as specified byagencyprocedure;

label the tubing, dressing, and solution bags clearly, indicating the date and time.

7. Document the specifics about the procedure such as num- ber of attempts at insertion; the

insertion site, type and size of device, solution and flow rate, and time; and the client’s response. In addition, follow agency procedure for docu- mentation of procedure.

The nurse checks the HCP’s prescription for the IV line and then determines the type and size of infusion device. The type and size are important to ensure adequate flowofthe prescribed solution. For example, ifa blood product is prescribed, the nurse would need to insert an appropriate catheter gauge size for blood delivery. The nurse also considers the client’s size, age, mobility, and other factors in selecting the type and size of the infusion device. The nurse prepares the appropriate IV tubing or extension set and primes the IV tubing or extension set to remove air from the system. The appropriate vein is selected, the tourniquet is applied, and the vein is checked and palpated for resilience. Strict surgical asepsis is employed and the skin is cleaned with an antimicrobial solution (as specified by agency policy), using an inner to outer circular motion. The vein is stabilized to prevent its movement and the skin is punctured. Blood in the flashback chamber indicates that the device is in the vein and when noted the catheter is carefully advanced to avoid puncture of the back wall of the vein. The tourniquet is removed, the stylet is removed from the catheter device, the IVtubing or extension set is connected, and the IVflowis started. Following assessment of the client and site, the nurse tapes and secures the site and labels the tubing, dressing, and solution bag appropriately and according to agency policy. The nurse checks the site and ensures that the solution is flowing. Finally, the nurse documents the specifics about the procedure.

Reference Perry, Potter, Ostendorf(2014), pp. 697, 701-703.

PRIORITYNURSING ACTIONS

Removing a Peripheral Intravenous Line

1. Check the health care provider’s (HCP’s) prescription and explain the procedure to the client;

ask the client to hold the extremity still during cannula or needle removal.

2. Turn offthe intravenous (IV) tubing clamp and remove the dres- sing and tape covering the site, while

stabilizing the catheter.

3. Apply light pressure with sterile gauze or other material as specified by agency procedure over the

site and withdraw the catheter using a slow, steady movement, keeping the hub parallel to the skin.

4. Apply pressure for 2 to 3 minutes, using dry sterile gauze (apply pressure for a longer period of

time if the client has a bleeding disorder or is taking anticoagulant medication).

5. Inspect the site for redness, drainage, or swelling; check the catheter for intactness.

6. Apply dressing as needed per agency policy.

7. Document the procedure and the client’s response.

The nurse checks for an HCP’s prescription to remove the IV line and then explains the procedure to the client. The nurse asks the client to hold the extremitystill during removal. The IVtubing clamp is placed in the off position and the dressing and tape are removed. The nurse is carefulto stabilize the catheter so that it is not pulled, resulting in vein trauma. Light pressure is applied over the site to stabilize the catheter and it is removed using a slow, steady movement, keeping the hub parallel to the skin. Pressure is applied until hemostasis occurs. The site is inspected for redness, drainage, or swelling and the catheter is checked for intactness to ensure that no part of it has broken off. A dressing is applied as needed per agency policy. Finally, the nurse documents the procedure and the client’s response.

Reference Perry, Potter, Ostendorf (2014), pp. 723-724.

150 UNIT III Nursing Sciences

FIGURE 13-5 Intravenous fluid bag with medication label and time- tape. (From Potter et al., 2013.)

e. Monitor for signs of circulatory overload. If circulatory overload occurs, decrease

the flow rate to a mi n i mu m, at a keep-vein-open rate; elevate the head of the bed; keep the client warm; assess lung sounds; assess for edema; and notify the HCP.

Clients with respiratory, cardiac, renal, or liver dis- ease; older clients; and very young persons are at risk for circulatory overload and cannot tolerate an excessive fluid volume.

D. Electrolyte overload

1. Description: An electrolyte imbalance is caused by too rapid or excessive infusion or

by use o f an inappropriate IV solution.

2. Prevention and interventions

a. Assess laboratory value reports.

b. Verify the correct solution.

c. Calculate and mon it or the flow rate.

d. Use an electronic IV infusion device and fre- quently check the drip rate or

setting (at least every h ou r for an adult).

e. Add a time tape (label) to the IV bag or bottle (see Fig. 13-5 ).

f. Place a red medication sticker on the bag or bottle if a medication has been

added to the IV solution (see Fig. 13-5 ).

g. Monitor for signs of an electrolyte imbalance, and notify the HCP if they occur.

Lactated Ringer’s solution contains potassium and should not be administered to clients with acute kidney injury or chronic kidney disease.

E. H emat oma

1. Description: Th e collection of blood in the tis- sues after an un successful venipuncture

or after the venipuncture site is discontinued and blood con tinues to ooze into the tissue

2. Prevention and interventions

a. When starting an IV, avoid piercing the poste- rior wall of the vein.

b. Do not apply a tourniquet to the extremity im- mediately after an unsuccessful

venipuncture.

c. When discontinuing an IV, apply pressure to the site for 2 to 3 minut es and

elevate the extrem ity; apply pressure longer for clients with a bleeding disorder or who are taking anticoagulants.

d. If a hema t o ma develops, elevate the extremity and apply pressure and ice as

prescribed.

e. Docu ment accordingly, including taking pictures of the IV site if indicated by

agency policy.

F. Infection

1. Description

a. Infection occurs from the entry of microor- gan isms into the body through the

ven ipunc- ture site.

b. Venipuncture interrupts the integrity of the skin , the first line of defen se against

infection.

c. Th e longer the therapy continues, the greater the risk for infection.

d. Infection can occur locally at the IV insertion site or system ically from the entry of

microor- ganisms into the body.

2. At-risk clients

a. Immu noco mpr omis ed clients with diseases such as cancer, hu ma n

immunodeficiency virus or acquired immunodeficiency syn - drome, thos e receiving biologic modifier response medications for treatment of auto- i m mu n e conditions, or status post organ transplant are at risk for infection.

b. Clients receiving treatments such as chemo- therapy who have an altered or

lowered white blood cell count are at risk for infection.

c. Older clients, because aging alters the effec- tiveness of the i m mu n e system, are

at risk for in fection.

d. Clients with diabetes mellitus are at risk for infection.

3. Prevention and interventions

a. Assess the client for predisposition to or risk for in fection.

b. Maintain strict asepsis when caring for the IV site.

c. Monitor for signs of local or systemic

infection.

CHAPTER 13 Intravenous Therapy 151

d. Monitor white blood cell counts.

e. Check fluid containers for cracks, leaks, cloud- iness, or other evidence of

conta mination.

f. Change IV tubing every 96 hours in accor- dance with CDC recommendat ions

o r according to agency policy; change IV site dressing when soiled or contaminated and according to agen cy policy.

g. Label the IV site, bag or bottle, and tubing with the date and time to ensure

that these are changed on time according to agency policy.

h. En sure that the IV solution is not hanging for more than 24 hours.

i. If infection occurs, the HCP is notified; dis- con tinue the IV, and place the

venipun cture device in a sterile container for possible culture.

j. Prepare to obtain blood cultures as pre- scribed if infection occurs and

docu ment accordingly.

k. Restart an IV in the opposite arm to differen- tiate sepsis (systemic infection) from

local infection at the IV site.

l. Docu ment accordingly, including taking pictures of the IV site if indicated by

agency policy.

A client with diabetes mellitus usually does not re- ceive dextrose (glucose) solutions because the solution can increase the blood glucose level.

G. Infiltration

1. Description

a. Infiltration is seepage of the IVfluid out of the vein and into the surroundin g

interstitial spaces.

b. Infiltration occurs when an access device has become dislodged or perforates

the wall o f the vein or when venous backpressure occurs because of a clot or venospasm.

2. Prevention and interventions

a. Avoid venipuncture over an area of flexion.

b. An chor the cannula and a loop of tubing securely with tape.

c. Use an armboard or splint as needed if the cli- ent is restless or active.

d. Monitor the IV rate for a decrease or a cessa- tion of flow.

e. Evaluate the IV site for infiltration by occlud- ing the vein proximal to the IV

site. If the IV fluid continues to flow, the cannula is proba- bly outside the vein (infiltrated); if the IVflow stops after occlusion of the vein, the IVdevice is still in the vein.

f. Lower the IVfluid container below the IVsite, and mo nit or for the appearance

of blood in

the IV tubing; if blood appears, the IV device is most likely in the vein.

g. If infiltration has occurred, remove the IV device immediately; elevate the extrem

ity and apply compresses (warm or cool, depend- ing on the IV solution that was infusing and the HCP’s prescription) over the affected area.

h. Do not rub an infiltrated area, which can cause h emat oma.

i. Docu ment accordingly, including taking pic- tures of the IV site if indicated by

agency policy.

H. Phlebitis and thrombophlebitis

1. Description

a. Phlebitis is an inflammation of the vein that can occur from mechanical or

chemical (med- ication) trauma or from a local infection.

b. Phlebitis can cause the develop ment of a clot (thromb op hleb itis).

2. Prevention and interventions

a. Use an IV cannula smaller than the vein, and avoid using very small veins when

adminis- tering irritating solutions.

b. Avoid using the lower extremities (legs and feet) as an access area for the IV.

c. Avoid venipuncture over an area of flexion.

d. An chor the cannula and a loop of tubing securely with tape.

e. Use an armboard or splint as needed if the cli- ent is restless or active.

f. Change the venipuncture site every 72 to 96 hours in accordance with CDC

recom- mendat ions and agency policy.

g. If phlebitis occurs, remove the IV device immediately and restart it in the

opposite extrem ity; notify the HCP if phlebitis is sus- pected, and apply warm, moist compresses, as prescribed.

h. If thromb op hleb itis occurs, do not irrigate the IV catheter; remove the IV,

notify the HCP, and restart the IV in the opposite extremity.

i. Docu ment accordingly, including taking pic- tures if indicated by agency

policy.

I. Tissue damage

1. Description

a. Tissues most commonl y damaged include the skin , veins, and subcutaneous

tissue.

b. Tissue damage can be uncomfortable and can cause per ma nent negative effects.

c. Extravasation is a form of tissue damage caused by the seepage of vesican t or

irritant solution s into the tissues; this occurrence requires immediate HCP notification so that treatment can be prescribed to prevent tissue necrosis.

CHAPTER 13 Intravenous Therapy 153

CRITICALTHINKING What Should You Do?

Answer: When a client has any type of central venous cath-

eter, there is a risk for breaking of the catheter, dislodgement

of a thrombus, or entry of air into the circulation, all of which

can lead to an embolism. Signs and symptoms that this com-

plication is occurring include sudden chest pain, dyspnea,

tachypnea, hypoxia, cyanosis, hypotension, and tachycardia.

If this occurs, the nurse should clamp the catheter, place the

client on the left side with the head lower than the feet (to

trap the embolism in the right atrium of the heart), adminis-

ter oxygen, and notify the health care provider.

Reference: Ignatavicius, Workman (2016), p. 207.

P R AC T I C E Q U E S T I O N S

skin to the exit site where the catheter comes out of the chest; the catheter at the exit site is secured by means of a "cuff" just under the skin at the exit site.

4. Th e catheter is fitted with an intermittent infu- sion device to allow access as needed

and to keep the system closed and intact.

5. Patency is maintained by flushing with a diluted heparin solution or nor ma l saline

solution, dep ending on the type of catheter, per agency policy.

C. Vascular access ports (imp lantable port)

1. Surgically implanted under the skin, ports such as a Port-a-Cath, Mediport, or Infusaport are

used for long-term adm inistration of repeated IV therapy.

2. For access, the port requires palpation and injec- tion through the skin into the self-

sealing port with a noncoring needle, such as a Huber point needle.

3. Patency is maintained by periodic flushing with a diluted heparin solution as

prescribed and as per agen cy policy.

D. PICC line

1. Th e catheter is used for long-term IVtherapy, fre- quently in the h o me.

2. Th e basilic vein usually is used, but the median cubital and ceph alic veins in the

antecubital area also can be used.

3. Th e catheter is threaded so that the catheter tip ma y terminate in the subclavian vein

or superior ven a cava.

4. A small a mou nt of bleeding may occur at the time of insertion and ma y continue

for 24 hours, but bleeding thereafter is not expected.

5. Phlebitis is a commo n complication.

IX. Epidural Catheter (Fig. 13-7)

A. Catheter is placed in the epidural space for the administration of analgesics; this met hod of

admin- istration reduces the a mo u nt of medication needed to control pain; therefore, the client experiences fewer side effects.

B. Assess client’s vital signs, level of consciousness, and

mot or and sensory function of lower extremities.

S keleta l vertebra

Epidural catheter

FIGURE 13-7 Tunneled epidural catheter.

C. Monitor insertion site for signs of infection and be sure that the catheter is secured to the

client’s skin and that all connections are taped to prevent disconnection.

D. Check HCP’s prescription regarding solution and

medication administration.

E. For cont inu ous infusion, monit or the electronic infusion device for proper rate of flow.

F. For bolus dose administration, follow the procedure for administering bolus doses

through the catheter and follow agency procedure.

G. Aspiration is done before injecting medication; if more than 1 m L of clear fluid or blood

returns, the m edication is not injected and the HCP or anesthesi- ologist is notified immediately (catheter may have m igrated into the subarachnoid space or a blood vessel).

Contraindications to an epidural catheter and administration of epidural analgesia include skeletal and spinal abnormalities, bleeding disorders, use of anti- coagulants, history of multiple abscesses, and sepsis.

103. A client had a 1000-m L bag of 5% dextrose in 0.9% sodium chloride hu n g at 1500. Th e

nurse making rou nds at 1545 finds that the client is com plaining of a p ou n d i n g headach e and is dys- pneic, experiencing chills, and apprehensive, with an increased pulse rate. Th e intravenous (IV) bag has 400 m L remainin g. Th e nurse should take which action first?

1. Slow the IV infusion.

2. Sit the client up in bed.

3. Remove the IV catheter.

4. Call the health care provider (HCP).

104. Th e nurse has a prescription to ha ng a 1000-m L intravenous (IV) bag of 5% dextrose in

water with 20 m Eq of potassium chloride. Th e nurse also needs to ha ng an IV in fusion of piperacillin/

154 UNIT III Nursing Sciences

tazobactam. The client has one IV site. The nurse should plan to take which action first?

1. Start a second IV site.

2. Check compatibility of the medication and IV fluids.

3. Mix the prepackaged piperacillin/ tazobactam per agency policy.

4. Prime the tubing with the IVsolution, and back- prime the medication.

105. Th e nurse is completing a time tape for a 1000-m L intravenous (IV) bag that is

scheduled to infuse over 8 hours. Th e nurse has just placed the 1100 marking at the 500- m L level. Th e nurse would place the mark for 1200 at which numerical level (m L) on the time tape? Fill in t he b la nk.

Answer: mL

106. Th e nurse is making initial r ou nds on the nursing unit to assess the condition of

assigned clients. Wh ich assessment findings are consistent with infiltration? Select all t hat apply.

1. Pain and erythema

2. Pallor and coolness

3. Nu mb ness and pain

4. Edema and blanched skin

5. Formation of a red streak and purulent

drainage

107. Th e nurse is inserting an intravenous (IV) line into a client’s vein. After the initial stick,

the nurse would continue to advance the catheter in which situation?

1. The catheter advances easily.

2. The vein is distended under the needle.

3. The client does not complain of discomfort.

4. Blood return shows in the backflash chamber of the catheter.

108. Th e nurse is assessing a client’s peripheral intrave- n ou s (IV) site after completion of a

van com ycin infusion and notes that the area is reddened, warm, painful, and slightly edematous proxim al to the insertion point of the IV catheter. At this time, which action by the nurse is best?

1. Check for the presence of blood return.

2. Remove the IV site and restart at another site.

3. Docu ment the findings and continue to mo ni- tor the IV site.

4. Call the health care provider (HCP) and request that the vancomycin be given

orally.

109. The nurse is preparing a continu ous intravenous

(IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. Th e nurse should take which action?

1. Obtain a new IV bag.

2. Obtain new IV tubing.

3. Wipe the spike end of the tubing with povidone iodine.

4. Scrub the spike end of the tub ing with an alco- ho l swab.

110. A health care provider has written a prescription to discontinue an intravenous (IV) line.

Th e nurse sh ould obtain which item from the unit supply area for applying pressure to the site after removing the IV catheter?

1. Elastic wrap

2. Povidone iodine swab

3. Adhesive bandage

4. Sterile 2 Â 2 gauze

111. A client rings the call light and complains of pain at the site of an intraven ous (IV)

infusion. Th e nurse assesses the site and determines that phlebi- tis has developed. Th e nurse should take which actions in the care of this client? Select all t hat apply.

1. Remove the IV catheter at that site.

2. Apply warm moist packs to the site.

3. Notify the health care provider (HCP).

4. Start a new IV line in a proximal portion of the same vein.

5. Docu ment the occurrence, actions taken, and the client’s

response.

112. A client involved in a mot or vehicle crash presents to the emergency department with

severe internal bleeding. Th e client is severely hypotensive and unresponsive. Th e nurse anticipates that which intravenous (IV) solution will mos t likely be pre- scribed for this client?

1. 5% dextrose in lactated Ringer’s solution

2. 0.33% sodium chloride (1/ 3 nor ma l saline)

3. 0.45% sodium chloride (1/ 2 nor ma l saline)

4. 0.225% sodium chloride (1/ 4 n or ma l saline)

113. Th e nurse provides a list of instructions to a client being discharged to h o m e with a

peripherally inserted central catheter (PICC). Th e nurse deter- mines that the client needs further ins t r u ct ions if the client ma de which statement?

1. “I need to wear a MedicAlert tag or bracelet.”

2. “I need to restrict my activity while this catheter is in place.”

3. “I need to keep the insertion site protected when in the shower or bath.”

4. “I need to check the markings on the catheter each time the dressing is

changed.”

114. A client has just undergone insertion of a central ven ous catheter at the bedside under

ultrasound. The nurse would be sure to check which results

156 UNIT^ III^ Nursing^ Sciences

Priority Concepts: Clinical Judgm ent; Tissue Integrity Refer ence: Ignatavicius, Workman (2016), p. 204.

107. 4 Ra tionale: Th e IV catheter has entered the lumen of the vein successfully when blood backflash sh ows in the IV catheter. Th e vein should have been distended by the tourniquet before the vein was cannulated, and if further distention occurs after ven ipuncture, this could mean the needle went through the vein and into the tissue; therefore, the catheter should not be advanced. Client discomfort varies with the client, the site, and the nurse’s insertion technique and is not a reliable measure of catheter placement. Th e nurse should not advance the catheter until placement in the vein is verified by blood return. Test-Ta king Strategy: Focus on the sub ject of the question, correct placement of an IV cath eter. Noting the words blood return in the correct option will direct you to this option because a blood return is expected if the catheter is in a vein. Review: Insertion of an in t raven o u s cath eter Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity

Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Medications and Intravenous Therapy Priority Concepts: Clinical Judgm ent; Perfusion Refer ence: Perry, Potter, Ostendorf (2014), pp. 703-704.

108. 2 Ra tionale: Phlebitis at an IV site can be distinguished by cli- ent discomfort at the site and by redness, warmth, and swell- ing proximal to the catheter. If phlebitis occurs, the nurse sh ould remove the IV line and in sert a new IV line at a differ- ent site, in a vein other than the one that has developed phle- bitis. Checking for the presence of blood return should be done before the administration of vancomycin because this medication is a vesicant. Documenting the findings and con- tinuing to monit or the IV site and calling the HCP and requesting that the vancomycin be given orally do not address the immediate problem. Addition ally, there could be indica- tions for the prescription of IV as opposed to oral vancomycin for the client. Th e HCP should be notified of the complica- tions with the IV site, but not asked for a prescription for oral van com ycin. Test-Ta king Strategy: Note the s t ra t egic w or d, best. Also, d et er mi n e if an a b n or ma l it y exists. Based on the assessment fin dings noted in the question, it is clear that an abnormality does exist, so eliminate docum enting and continuing to mo n- itor. Next, recalling the appropriate nursing intervention for phlebitis will direct you to the correct option. Review: Sign s and symptoms of ph lebitis and the associated nursing interventions Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Medications and Intravenous Therapy Priority Concepts: Clinical Judgm ent; Tissue Integrity Refer ence: Ignatavicius, Workman (2016), p. 205.
109. 2 Ra tionale: Th e nurse should obtain new IV tubing because con tamination has occurred and could cause systemic infec- tion to the client. Th ere is no need to obtain a new IV bag because the bag was not contaminated. Wiping with povidone iodine or alcohol is insufficient and is contraindicated because the spike will be inserted into the IV bag. Test-Ta king Strategy: Focus on the s u b ject , that the tubing was contaminated. Use knowledge of basic infection control measures and IV therapy concepts to answer this question. Rem ember that if an item is contaminated, discard it and obtain a new sterile item. Review: Surgical as ep t ic tech n iqu e Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Medications and Intravenous Therapy Priority Concepts: Clinical Judgm ent; Infection Reference: Perry, Potter, Ostendorf (2014), p. 700.
110. 4 Ra tionale: A dry sterile dressing such as a sterile 2 Â 2 gauze is used to apply pressure to the discontinued IVsite. Th is material is absorbent, sterile, and nonirritating. Apovidone iodine swab would irritate the opened puncture site and would not stop the blood flow. An adhesive bandage or elastic wrap may be used to cover the site once hemostasis has occurred. Test-Taking Strategy: Focus on the subject, care to the IV site after removal of the catheter, and note the words applying pressure. Visualize this procedure, thinking about each of the items identified in the options to direct you to the correct option. Review: In traven o u s cath eter r emo va l Level of Cognitive Ability: Applyin g Client Needs: Physiological Integrity

Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Medications and Intravenous Therapy Priority Concepts: Clinical Judgm ent; Clotting Refer ence: Perry, Potter, Ostendorf (2014), p. 723.

111. 1, 2, 3, 5 Ra tionale: Phlebitis is an inflammation of the vein that can occur from mechanical or chemical (medication) trauma or from a local in fection and can cause the development of a clot (thrombophlebitis). Th e nurse should remove the IV at the phlebitic site and apply warm moist compresses to the area to speed resolution of the inflammation. Because phlebitis has occurred, the nurse also notifies the HCP about the IV com plication. Th e nurse should restart the IV in a vein other than the one that has developed phlebitis. Finally, the nurse documents the occurrence, actions taken, and the client’s response. Test-Taking Strategy: Focus on the subject, actions to take if phlebitis occurs. Recall that phlebitis is an inflammation of the vein. Th is will assist in eliminating the option that indicates to use the same vein because an IVshould be restarted in a vein other than the one that has developed phlebitis.

Review: Ph lebitis

CHAPTER 13 Intravenous Therapy 157

Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Ar ea: Critical Care—Medications and Intravenous Therapy Priority Concepts: Clinical Judgm ent; Inflammation Refer ence: Ignatavicius, Workman (2016), p. 205.

112. 1 Ra tionale: For this client, the goal of therapy is to expand intra- vascular volume as quickly as possible. In this situation, the cli- ent will likely experien ce a decrease in intravascular volume from blood loss, resulting in decreased blood pressure. Th ere- fore, a solution that increases intravascular volume, replaces immediate blood loss volume, and increases blood pressure is needed. Th e 5% dextrose in lactated Ringer’s (hypertonic) solution would increase intravascular volume and immedi- ately replace lost fluid volume until a transfusion could be administered, resulting in an increase in the client’s blood pres- sure. Th e solution s in the remaining options would not be given to this client because they are hypotonic solutions and, instead of increasing intravascular space, the solutions would move into the cells via osmosis. Test-Ta king Strategy: Focus on the s u b ject , that the client has been in a traumatic accident. Also, note the s t ra t egic w or ds , most likely. Also not e that the incorrect options are c o mp a r a b le or alike and include a % of normal saline. Determining that this client will likely experience decreased intravascular volume and blood pressure due to blood loss and recalling IV fluid types and how hypotonic and hypertonic solutions function within the intravascular space will direct you to the correct option.

Review: In traven o u s flu ids

Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Ar ea: Critical Care—Medications and Intravenous Therapy Priority Concepts: Clinical Judgm ent; Perfusion Refer ence: Perry, Potter, Ostendorf (2014), p. 694.

113. 2 Ra tionale: Th e client should be taught that only minor activity restrictions apply with this type of catheter. Th e client should carry or wear a MedicAlert identification and should protect the site during bathing to prevent infection. Th e client sh ould ch eck the markin gs on the cath eter during each dressing change to assess for catheter migration or dislodgem ent. Test-Ta king Strategy: Note the s t ra t egic w or ds , needs further instructions. Th ese words indicate a n egative even t q u er y and the need to select the incorrect client statement. Recalling that the PICC is for long-term use will assist in directing you to the correct option. To restrict activity with such a cath eter is unreasonable. Review: P er ip h erally ins er t ed intraven ou s cath et er s Level of Cognitive Ability: Evaluatin g Client Needs: Physiological Integrity Integrated Process: Teaching and Learning

Content Ar ea: Critical Care—Medications and Intravenous Therapy Priority Concepts: Client Education; Functional Ability Refer ence: Perry, Potter, Ostendorf (2014), p. 735.

114. 4 Ra tionale: Before beginning administration of IVsolution, the nurse should assess whether the chest radiology results reveal that the central catheter is in the proper place. Th is is necessary to prevent infusion of IVfluid into pulmonary or subcutaneous tissues. Th e other options represent items that are useful for the nurse to be aware of in the general care of this client, but they do not relate to this procedure. Test-Ta king Strategy: Note the s u b ject , care to the client with a central venous catheter. Note the words insertion of a central venous catheter at the bedside. Recalling the potential complica- tions associated with the insertion of central venous catheters will direct you to the correct option. Review: Nursing actions related to cen t r a l ven ou s cath et ers Level of Cognitive Ability: An alyzing

Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Ar ea: Critical Care—Medication s and Intravenous Therapy Priority Concepts: Clinical Judgment; Safety Refer ences: Ignatavicius, Workman (2016), pp. 190-191, 193; Perry, Potter, Ostendorf (2014), p.

736. 2 Ra tionale: Circulatory (fluid) overload is a complication of IV therapy. Sign s include rapid breathing, dyspnea, a moist cough , and crackles. Blood pressure and heart rate also in crease if circulatory overload is present. Th erefore, since the nurse pre- viously noted rapid breathing and cough in g, the nurse should then assess for a moist cough and crackles. Hemat oma is another potential complication and is characterized by ecchy- mosis, swelling, and leakage at the IV insertion site, as well as hard and painful lu mps at the site. Allergic reaction is a com- plication of administration of IV fluids or medication and is ch aracterized by chills, fever, malaise, headache, nausea, vom itin g, backach e, and tach ycardia; this type of reaction could also occur if the IV solutions infused are in com patible; however, there was no indication of multiple solutions being infused simultaneously in this question. Chest pain radiating to the left arm is a classic sign of cardiac compromise and is not specifically related to a complication of IV therapy. Test-Ta king Strategy: Focus on th e da t a in th e q u es t i o n and note the s u b ject, a complication. Noting that the client is experien cing rapid breathing and is coughing will assist in directing you to the correct option. Review: Signs of cir cu lat or y over loa d Level of Cognitive Ability: Synthesizing Client Needs: Physiological Integrity

Integrated Process: Nursing Process—Analysis Content Ar ea: Critical Care—Medications and Intravenous Therapy Priority Concepts: Clinical Judgm ent; Perfusion Refer ence: Ignatavicius, Workman (2016), p. 207.