Questions| With Correct Answers.
1). Match the appropriate nursing intervention to the unexpected outcome.
hematoma formation
site is reddened and tender
catheter tip is broken off
notify health care provider immediately because this is an emergency situation.
discontinue iv site and notify health care provider. may apply warm moist pack.
apply a pressure dressing to the site.
Ans: Hematoma formation - Apply a pressure dressing to the site.
Site is reddened and tender - Discontinue IV site and notify health care provider. May apply
warm moist pack.
Catheter tip is broken off - Notify health care provider immediately because this is an
emergency situation.
2). The student nurse is watching the staff nurse discontinue a peripheral iv. the staff nurse
removes the catheter and then looks at it. the student asks the nurse what she is looking for.
what would be a correct response?
"i'm noting the gauge of the catheter so i can document removal accurately."
"i am inspecting the catheter for intactness."
"to see if there is exudate at the catheter tip."
"to see if there is any clot formation on the tip."
Ans: "I am inspecting the catheter for intactness."
Clot formation may be an indication for discontinuing an IV, but the primary reason for
observing the catheter tip is to determine that it is intact. The tip of the catheter can break
off, causing an embolus and an emergency situation. The gauge size should be written on
the dressing and recorded in the nurse's notes. Signs of infection may be an indication for
discontinuing an IV.
3). What is the primary danger related to a broken catheter tip?
infection.
hematoma formation.
embolus.
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