NURSING
NURS 311 Clinical Nursing Skills Final
Exam
Infusion Nursing Society (INS) standards for reducing infection related to IV Therapy - -•
Assess the VAD catheter-skin junction site and surrounding area for redness,
tenderness, swelling, and drainage by visual inspection and palpation through the intact
dressing. Assess short-peripheral catheters minimally at least every 4 hours or more if
clinically indicated and daily for outpatient or home care patients. CVADs should be
assessed at least daily.
• Change the dressing immediately to assess, clean, and disinfect the site in the event
of drainage, tenderness, other signs of infection or if dressing becomes loose or
dislodged.
• Perform hand hygiene before placing and providing any VAD-associated interventions.
• Perform dressing changes at a frequency based on the type of catheter and dressing.
Short-peripheral catheter dressings are changed if the dressing becomes damp,
loosened, and/or visibly soiled; if there is blood or drainage under the dressing; and at
least every 5-7 days. Change CVAD dressings at least every 5-7 days for TSM
dressings and at least every 2 days for gauze dressings that cover a catheter site or are
under a TSM.
• Use approved antiseptic agents before venipuncture and when performing skin
antisepsis. The preferred skin antiseptic is >0.5% chlorhexidine gluconate (CHG) in
alcohol solution. Tincture of iodine, an iodophor (povidone-iodine), or 70% alcohol may
be used if CHG solution is contraindicated.
• Allow skin antiseptic to dry fully before dressing placement; alcoholic chlorhexidine
solutions, for at least 30 seconds; iodophors, for at least 1.5-2 minutes.
• Use catheter stabilization device that allows visual inspection of access site.
• Use vigorous mechanical scrubbing methods when disinfecting needleless connectors
before each access using 70% isopropyl alcohol, iodophors, or >0.5% chlorhexidine
alcoholic solution. Disinfect before each access when multiple accesses are req
The Needle Safety and Prevention Act of 2001 - --Mandates that health care agencies
use safe needle devices and manufactured needleless systems to reduce needlestick
injury. Systems with catheter ports or Y-connector sites are designed to contain a
needle housed in a protective covering. Needleless infusion lines allow a direct
connection with the IV line via a recessed connection port, a blunt-ended cannula, or
shielded-needle device, eliminating the risk for exposure to an IV needle.
Recommendations for the Prevention of Needlestick Injuries - -• Avoid using needles
when effective needleless systems or sharps with engineered sharps injury protection
(SESIP) safety devices are available.
• Do not recap any needle after medication administration.
• Plan safe handling and disposal of needles before beginning a procedure.
NURSING
,NURSING
• Immediately dispose of needles, needleless systems, and SESIP into puncture-proof
and leak-proof sharps disposal containers.
• Maintain a sharps injury log that reports the following: type and brand of device
involved in the incident; location of the incident (e.g., department or work area);
description of the incident; and privacy of the employees who have had sharps injuries.
• Attend education offerings on bloodborne pathogens and follow recommendations for
infection prevention, including receiving the hepatitis B vaccine.
• Participate in the selection and evaluation of SESIP devices with safety features within
your agency whenever possible.
Isotonic solutions - -•Dextrose 5% in water
-Dextrose is quickly metabolized, leaving free water to be distributed evenly in all fluid
compartments so it acts like a hypotonic solution
•0.9% sodium chloride† (NS)
•Lactated Ringer's‡
-Has multiple electrolytes
Hypotonic solutions - -•0.45% sodium chloride (half NS)
•0.33% sodium chloride (one-third NS)
Hypertonic solutions - -•Dextrose 10% in water
•Dextrose 50% in water
•3%-5% sodium chloride
•Dextrose 5% in 0.9% sodium chloride
•Dextrose 5% in 0.45% NaCl sodium chloride
•Dextrose 5% in Lactated Ringer's
Prepare IV tubing and solution for continuous infusion. - -a. Check IV solution using six
rights of medication administration and review label for name and concentration of
solution, type and concentration of any additives, volume, beyond-use and expiration
dates, and sterility state. If using bar code, scan code on patient's wristband and then
on IV fluid container. Be sure that prescribed additives such as potassium and vitamins
have been added. Check solution for color and clarity. Check bag for leaks.
b. Open IV infusion set, maintaining sterility. NOTE: EIDs sometimes have a dedicated
administration set; follow manufacturer's instructions.
c. Place roller clamp about 2 to 5 cm (1 to 2 inches) below drip chamber and move roller
clamp to "off" position.
d. Remove protective sheath over IV tubing port on plastic IV solution bag or top of IV
solution bottle while maintaining sterility.
e. Remove protective cover from IV tubing spike while maintaining sterility of spike.
Insert spike into port of IV bag using a twisting motion. If solution container is glass
NURSING
,NURSING
bottle, clean rubber stopper on glass-bottled solution with antiseptic swab and insert
spike into rubber stopper of IV bottle. Bottles require vented tubing.
f. Compress drip chamber and release, allowing it to fill one-third to one-half full
g. Prime air out of IV tubing by filling with IV solution: Remove protective cover on end
of IV tubing (some tubing can be primed without removing protective cover) and slowly
open roller clamp to allow fluid to flow from drip chamber to distal end of IV tubing. If
tubing has a Y connector, invert Y connector when fluid reaches it to displace air.
Return roller clamp to "off" position after priming tubing (filled with IV fluid). Replace
protective cover on distal end of tubing. Label IV tubing with date according to agency
policy and procedure.
h. Be certain that IV tubing is
Starting and IV Implementation - -1. Swabs injection cap and primes saline lock leaving
syringe attached. Loosens protector cap (maintain sterility). Removes over needle
catheter (ONC) and transparent dressing from wrappers.
2. Applies tourniquet 4 - 6 inches above selected site (check radial pulse) and assesses
vein for appropriateness. If need additional prep time may release tourniquet
temporarily.
3. Applies clean gloves
4. Moves saline lock nearby, on over-the-bed table, maintaining in sterile package.
5. Cleanses site with Chlorhexidine - using friction horizontal, vertical, and circular.
Cleanse for at least 30 seconds and allow site to completely dry. Do not touch site!
6. Performs venipuncture: Anchors vein 1.5-2 inches below insertion site by gently
stretching the skin against the direction of insertion site. Be sure not to touch the
cleansed site or allow the ONC to touch the anchoring thumb; advises patient to remain
still and that there will be a quick stick; inserts ONC with bevel up at 10-30 ° angle in the
direction parallel to the vein.
7. Observes for blood return. Lowers needle and advances 1/4 inch.
8. Continues to hold skin and advances catheter all the way to hub without advancing
the stylet/needle. Stabilizes catheter with one hand and releases tourniquet with the
other hand. (Push and pop)
9. Apply gentle/firm pressure 1 1⁄4 inch above insertion site and removes stylet/needle
of ONC. Disposes of stylet in sharps container if close or temporarily places on bedside
table away from patient.
10. Removes cap and maintains sterility; quickly connects end of saline lock to catheter.
Secures temporarily with tape.
11. Reassesses for blood return with gentle aspiration and flushes the vein with
remaining saline, observing site for swelling. Removes flush syringe and places in
sharps container.
12. Applies a sterile transparent dressing
Principles for Vein selection - --Veins on dorsal and ventral surfaces of arms (e.g.,
metacarpal, cephalic, basilic, or median) are preferred in adults.
NURSING
, NURSING
image
- Use most distal site in nondominant arm if possible.
Patients with VAD placement in their dominant hand have decreased ability to perform
self-care.
- With your fingertip, palpate vein at intended insertion site by pressing downward. Note
resilient, soft, bouncy feeling while releasing pressure
- Select well-dilated vein
Methods to improve vascular distention - --Increased volume of blood in vein at
venipuncture site makes vein more visible.
(1) Position extremity lower than heart, have patient open and close fist slowly, and
lightly stroke vein downward.
(2) Apply dry heat to extremity for several minutes.
Avoid vein selection - -(1) Areas with pain on palpation, compromised areas, sites distal
to compromised areas (e.g., open wounds, bruising, infection, infiltration, or
extravasation)
(2) Upper extremity on side of breast surgery with axillary node dissection or
lymphedema or after radiation, arteriovenous (AV) fistulas/grafts; or affected extremity
from cerebrovascular accident (CVA)
(3) Site distal to previous venipuncture site, sclerosed or hardened veins, previous
infiltrations or extravasations, areas of venous valves, or phlebitic vessels.
(4) Fragile dorsal hand veins in older adults. Veins of lower extremities should not be
used for routine IV therapy in adults because of risk of tissue damage and
thrombophlebitis
(5) Areas of flexion such as wrist or antecubital area
(6) Ventral surface of wrist (10-12.5 cm [4-5 inches])
(7) Choose site that will not interfere with patient's activities of daily living (ADLs), use of
assist devices, or planned procedures.
Regulating Intravenous Flow Rates - -1. Regulate gravity infusion
2. Regulate EID
3. Attach label to IV solution container with date and time container changed (check
agency policy).
4. Teach patient purpose of EID if infusion therapy is delivered by EID, purpose of
alarms, to avoid raising hand or arm that affects flow rate, and to avoid touching control
clamp.
5. Remove and dispose of any used supplies; perform hand hygiene.
Regulate gravity infusion - -a. Ensure that IV container is at least 76.2 cm (30 inches)
above IV site for adults and increase height for more viscous fluids
b. Slowly open roller clamp on tubing until you can see drops in drip chamber. Hold a
watch with second hand at same level as drip chamber and count drip rate for 1 minute.
Adjust roller clamp to increase or decrease rate of infusion.
c. Monitor drip rate at least hourly.
NURSING
NURS 311 Clinical Nursing Skills Final
Exam
Infusion Nursing Society (INS) standards for reducing infection related to IV Therapy - -•
Assess the VAD catheter-skin junction site and surrounding area for redness,
tenderness, swelling, and drainage by visual inspection and palpation through the intact
dressing. Assess short-peripheral catheters minimally at least every 4 hours or more if
clinically indicated and daily for outpatient or home care patients. CVADs should be
assessed at least daily.
• Change the dressing immediately to assess, clean, and disinfect the site in the event
of drainage, tenderness, other signs of infection or if dressing becomes loose or
dislodged.
• Perform hand hygiene before placing and providing any VAD-associated interventions.
• Perform dressing changes at a frequency based on the type of catheter and dressing.
Short-peripheral catheter dressings are changed if the dressing becomes damp,
loosened, and/or visibly soiled; if there is blood or drainage under the dressing; and at
least every 5-7 days. Change CVAD dressings at least every 5-7 days for TSM
dressings and at least every 2 days for gauze dressings that cover a catheter site or are
under a TSM.
• Use approved antiseptic agents before venipuncture and when performing skin
antisepsis. The preferred skin antiseptic is >0.5% chlorhexidine gluconate (CHG) in
alcohol solution. Tincture of iodine, an iodophor (povidone-iodine), or 70% alcohol may
be used if CHG solution is contraindicated.
• Allow skin antiseptic to dry fully before dressing placement; alcoholic chlorhexidine
solutions, for at least 30 seconds; iodophors, for at least 1.5-2 minutes.
• Use catheter stabilization device that allows visual inspection of access site.
• Use vigorous mechanical scrubbing methods when disinfecting needleless connectors
before each access using 70% isopropyl alcohol, iodophors, or >0.5% chlorhexidine
alcoholic solution. Disinfect before each access when multiple accesses are req
The Needle Safety and Prevention Act of 2001 - --Mandates that health care agencies
use safe needle devices and manufactured needleless systems to reduce needlestick
injury. Systems with catheter ports or Y-connector sites are designed to contain a
needle housed in a protective covering. Needleless infusion lines allow a direct
connection with the IV line via a recessed connection port, a blunt-ended cannula, or
shielded-needle device, eliminating the risk for exposure to an IV needle.
Recommendations for the Prevention of Needlestick Injuries - -• Avoid using needles
when effective needleless systems or sharps with engineered sharps injury protection
(SESIP) safety devices are available.
• Do not recap any needle after medication administration.
• Plan safe handling and disposal of needles before beginning a procedure.
NURSING
,NURSING
• Immediately dispose of needles, needleless systems, and SESIP into puncture-proof
and leak-proof sharps disposal containers.
• Maintain a sharps injury log that reports the following: type and brand of device
involved in the incident; location of the incident (e.g., department or work area);
description of the incident; and privacy of the employees who have had sharps injuries.
• Attend education offerings on bloodborne pathogens and follow recommendations for
infection prevention, including receiving the hepatitis B vaccine.
• Participate in the selection and evaluation of SESIP devices with safety features within
your agency whenever possible.
Isotonic solutions - -•Dextrose 5% in water
-Dextrose is quickly metabolized, leaving free water to be distributed evenly in all fluid
compartments so it acts like a hypotonic solution
•0.9% sodium chloride† (NS)
•Lactated Ringer's‡
-Has multiple electrolytes
Hypotonic solutions - -•0.45% sodium chloride (half NS)
•0.33% sodium chloride (one-third NS)
Hypertonic solutions - -•Dextrose 10% in water
•Dextrose 50% in water
•3%-5% sodium chloride
•Dextrose 5% in 0.9% sodium chloride
•Dextrose 5% in 0.45% NaCl sodium chloride
•Dextrose 5% in Lactated Ringer's
Prepare IV tubing and solution for continuous infusion. - -a. Check IV solution using six
rights of medication administration and review label for name and concentration of
solution, type and concentration of any additives, volume, beyond-use and expiration
dates, and sterility state. If using bar code, scan code on patient's wristband and then
on IV fluid container. Be sure that prescribed additives such as potassium and vitamins
have been added. Check solution for color and clarity. Check bag for leaks.
b. Open IV infusion set, maintaining sterility. NOTE: EIDs sometimes have a dedicated
administration set; follow manufacturer's instructions.
c. Place roller clamp about 2 to 5 cm (1 to 2 inches) below drip chamber and move roller
clamp to "off" position.
d. Remove protective sheath over IV tubing port on plastic IV solution bag or top of IV
solution bottle while maintaining sterility.
e. Remove protective cover from IV tubing spike while maintaining sterility of spike.
Insert spike into port of IV bag using a twisting motion. If solution container is glass
NURSING
,NURSING
bottle, clean rubber stopper on glass-bottled solution with antiseptic swab and insert
spike into rubber stopper of IV bottle. Bottles require vented tubing.
f. Compress drip chamber and release, allowing it to fill one-third to one-half full
g. Prime air out of IV tubing by filling with IV solution: Remove protective cover on end
of IV tubing (some tubing can be primed without removing protective cover) and slowly
open roller clamp to allow fluid to flow from drip chamber to distal end of IV tubing. If
tubing has a Y connector, invert Y connector when fluid reaches it to displace air.
Return roller clamp to "off" position after priming tubing (filled with IV fluid). Replace
protective cover on distal end of tubing. Label IV tubing with date according to agency
policy and procedure.
h. Be certain that IV tubing is
Starting and IV Implementation - -1. Swabs injection cap and primes saline lock leaving
syringe attached. Loosens protector cap (maintain sterility). Removes over needle
catheter (ONC) and transparent dressing from wrappers.
2. Applies tourniquet 4 - 6 inches above selected site (check radial pulse) and assesses
vein for appropriateness. If need additional prep time may release tourniquet
temporarily.
3. Applies clean gloves
4. Moves saline lock nearby, on over-the-bed table, maintaining in sterile package.
5. Cleanses site with Chlorhexidine - using friction horizontal, vertical, and circular.
Cleanse for at least 30 seconds and allow site to completely dry. Do not touch site!
6. Performs venipuncture: Anchors vein 1.5-2 inches below insertion site by gently
stretching the skin against the direction of insertion site. Be sure not to touch the
cleansed site or allow the ONC to touch the anchoring thumb; advises patient to remain
still and that there will be a quick stick; inserts ONC with bevel up at 10-30 ° angle in the
direction parallel to the vein.
7. Observes for blood return. Lowers needle and advances 1/4 inch.
8. Continues to hold skin and advances catheter all the way to hub without advancing
the stylet/needle. Stabilizes catheter with one hand and releases tourniquet with the
other hand. (Push and pop)
9. Apply gentle/firm pressure 1 1⁄4 inch above insertion site and removes stylet/needle
of ONC. Disposes of stylet in sharps container if close or temporarily places on bedside
table away from patient.
10. Removes cap and maintains sterility; quickly connects end of saline lock to catheter.
Secures temporarily with tape.
11. Reassesses for blood return with gentle aspiration and flushes the vein with
remaining saline, observing site for swelling. Removes flush syringe and places in
sharps container.
12. Applies a sterile transparent dressing
Principles for Vein selection - --Veins on dorsal and ventral surfaces of arms (e.g.,
metacarpal, cephalic, basilic, or median) are preferred in adults.
NURSING
, NURSING
image
- Use most distal site in nondominant arm if possible.
Patients with VAD placement in their dominant hand have decreased ability to perform
self-care.
- With your fingertip, palpate vein at intended insertion site by pressing downward. Note
resilient, soft, bouncy feeling while releasing pressure
- Select well-dilated vein
Methods to improve vascular distention - --Increased volume of blood in vein at
venipuncture site makes vein more visible.
(1) Position extremity lower than heart, have patient open and close fist slowly, and
lightly stroke vein downward.
(2) Apply dry heat to extremity for several minutes.
Avoid vein selection - -(1) Areas with pain on palpation, compromised areas, sites distal
to compromised areas (e.g., open wounds, bruising, infection, infiltration, or
extravasation)
(2) Upper extremity on side of breast surgery with axillary node dissection or
lymphedema or after radiation, arteriovenous (AV) fistulas/grafts; or affected extremity
from cerebrovascular accident (CVA)
(3) Site distal to previous venipuncture site, sclerosed or hardened veins, previous
infiltrations or extravasations, areas of venous valves, or phlebitic vessels.
(4) Fragile dorsal hand veins in older adults. Veins of lower extremities should not be
used for routine IV therapy in adults because of risk of tissue damage and
thrombophlebitis
(5) Areas of flexion such as wrist or antecubital area
(6) Ventral surface of wrist (10-12.5 cm [4-5 inches])
(7) Choose site that will not interfere with patient's activities of daily living (ADLs), use of
assist devices, or planned procedures.
Regulating Intravenous Flow Rates - -1. Regulate gravity infusion
2. Regulate EID
3. Attach label to IV solution container with date and time container changed (check
agency policy).
4. Teach patient purpose of EID if infusion therapy is delivered by EID, purpose of
alarms, to avoid raising hand or arm that affects flow rate, and to avoid touching control
clamp.
5. Remove and dispose of any used supplies; perform hand hygiene.
Regulate gravity infusion - -a. Ensure that IV container is at least 76.2 cm (30 inches)
above IV site for adults and increase height for more viscous fluids
b. Slowly open roller clamp on tubing until you can see drops in drip chamber. Hold a
watch with second hand at same level as drip chamber and count drip rate for 1 minute.
Adjust roller clamp to increase or decrease rate of infusion.
c. Monitor drip rate at least hourly.
NURSING
