NURS 322 Exam 1 (Latest
update) Questions & Answers {Grade A}
100% Correct
A nurse assesses a clients peripheral IV site, and notices edema and tenderness
above the site. Which action should the nurse take next?
a. Apply cold compresses to the IV site.
b. Elevate the extremity on a pillow.
c. Flush the catheter with normal saline.
d. Stop the infusion of intravenous fluids. - Correct answer ANS: D
Infiltration occurs when the needle dislodges partially or completely from the vein.
Signs of infiltration include edema and tenderness above the site. The nurse should
stop the infusion and remove the catheter. Cold compresses and elevation of the
extremity can be done after the catheter is discontinued to increase client comfort.
Alternatively, warm compresses may be prescribed per institutional policy and may
help speed circulation to the area.
,While assessing a clients peripheral IV site, the nurse observes a streak of red along
the vein path and palpates a 4-cm venous cord. How should the nurse document this
finding?
a. Grade 3 phlebitis at IV site
b. Infection at IV site
c. Thrombosed area at IV site
d. Infiltration at IV site - Correct answer ANS: A
The presence of a red streak and palpable cord indicates grade 3 phlebitis. No
information in the description indicates that infection, thrombosis, or infiltration is
present.
A nurse responds to an IV pump alarm related to increased pressure. Which action
should the nurse take first?
a. Check for kinking of the catheter.
b. Flush the catheter with a thrombolytic enzyme.
c. Get a new infusion pump.
,d. Remove the IV catheter. - Correct answer ANS: A
Fluid flow through the infusion system requires that pressure on the external side be
greater than pressure at the catheter tip. Fluid flow can be slowed for many reasons. A
common reason, and one that is easy to correct, is a kinked catheter. If this is not the
cause of the pressure alarm, the nurse may have to ascertain whether a clot has
formed inside the catheter lumen, or if the pump is no longer functional. Removal of
the IV catheter and placement of a new IV catheter should be completed when no other
option has resolved the problem.
A nurse prepares to insert a peripheral venous catheter in an older adult client. Which
action should the nurse take to protect the client's skin during this procedure?
a. Lower the extremity below the level of the heart.
b. Apply warm compresses to the extremity.
c. Tap the skin lightly and avoid slapping.
d. Place a washcloth between the skin and tourniquet. - Correct answer ANS: D
, To protect the clients skin, the nurse should place a washcloth or the clients gown
between the skin and tourniquet. The other interventions are methods to distend the
vein but will not protect the clients skin.
A nurse delegates care to an unlicensed assistive personnel (UAP). Which statement
should the nurse include when delegating hygiene for a client who has a vascular
access device?
a. Provide a bed bath instead of letting the client take a shower.
b. Use sterile technique when changing the dressing.
c. Disconnect the intravenous fluid tubing prior to the clients bath.
d. Use a plastic bag to cover the extremity with the device. - Correct answer ANS: D
The nurse should ask the UAP to cover the extremity with the vascular access device
with a plastic bag or wrap to keep the dressing and site dry. The client may take a
shower with a vascular device. The nurse should disconnect IV fluid tubing prior to the
bath and change the dressing using sterile technique if necessary. These options are
not appropriate to delegate to the UAP.
update) Questions & Answers {Grade A}
100% Correct
A nurse assesses a clients peripheral IV site, and notices edema and tenderness
above the site. Which action should the nurse take next?
a. Apply cold compresses to the IV site.
b. Elevate the extremity on a pillow.
c. Flush the catheter with normal saline.
d. Stop the infusion of intravenous fluids. - Correct answer ANS: D
Infiltration occurs when the needle dislodges partially or completely from the vein.
Signs of infiltration include edema and tenderness above the site. The nurse should
stop the infusion and remove the catheter. Cold compresses and elevation of the
extremity can be done after the catheter is discontinued to increase client comfort.
Alternatively, warm compresses may be prescribed per institutional policy and may
help speed circulation to the area.
,While assessing a clients peripheral IV site, the nurse observes a streak of red along
the vein path and palpates a 4-cm venous cord. How should the nurse document this
finding?
a. Grade 3 phlebitis at IV site
b. Infection at IV site
c. Thrombosed area at IV site
d. Infiltration at IV site - Correct answer ANS: A
The presence of a red streak and palpable cord indicates grade 3 phlebitis. No
information in the description indicates that infection, thrombosis, or infiltration is
present.
A nurse responds to an IV pump alarm related to increased pressure. Which action
should the nurse take first?
a. Check for kinking of the catheter.
b. Flush the catheter with a thrombolytic enzyme.
c. Get a new infusion pump.
,d. Remove the IV catheter. - Correct answer ANS: A
Fluid flow through the infusion system requires that pressure on the external side be
greater than pressure at the catheter tip. Fluid flow can be slowed for many reasons. A
common reason, and one that is easy to correct, is a kinked catheter. If this is not the
cause of the pressure alarm, the nurse may have to ascertain whether a clot has
formed inside the catheter lumen, or if the pump is no longer functional. Removal of
the IV catheter and placement of a new IV catheter should be completed when no other
option has resolved the problem.
A nurse prepares to insert a peripheral venous catheter in an older adult client. Which
action should the nurse take to protect the client's skin during this procedure?
a. Lower the extremity below the level of the heart.
b. Apply warm compresses to the extremity.
c. Tap the skin lightly and avoid slapping.
d. Place a washcloth between the skin and tourniquet. - Correct answer ANS: D
, To protect the clients skin, the nurse should place a washcloth or the clients gown
between the skin and tourniquet. The other interventions are methods to distend the
vein but will not protect the clients skin.
A nurse delegates care to an unlicensed assistive personnel (UAP). Which statement
should the nurse include when delegating hygiene for a client who has a vascular
access device?
a. Provide a bed bath instead of letting the client take a shower.
b. Use sterile technique when changing the dressing.
c. Disconnect the intravenous fluid tubing prior to the clients bath.
d. Use a plastic bag to cover the extremity with the device. - Correct answer ANS: D
The nurse should ask the UAP to cover the extremity with the vascular access device
with a plastic bag or wrap to keep the dressing and site dry. The client may take a
shower with a vascular device. The nurse should disconnect IV fluid tubing prior to the
bath and change the dressing using sterile technique if necessary. These options are
not appropriate to delegate to the UAP.
