NUR 530|ATI IV Therapy Quiz answers/rationale,100% correct
ATI IV Therapy Quiz 1. A nurse is discontinuing an IV infusion. For which of the following reasons is it important to verify and document the integrity and condition of the IVC? a. “A broken-off catheter tip indicates the risk for an embolus” i. If the catheter tip breaks off the nurse should apply a tourniquet high on the extremity where the IV line was and immediately notify the provider b. “Catheter erosion indicates that it was left in place too long” i. Catheters are made of material that is highly unlikely to erode in the time they’re in place c. “Blood within the catheter could indicate clot formation” i. It’s typical to see blood inside the catheter upon removal—a clot at the tip is also normal d. “Discoloration of the catheter could be a sign of phlebitis” i. Phlebitis would not cause discoloration of the catheter 2. A nurse finds a patient’s IV insertion site red, warm, and slightly edematous. Which of the following actions should the nurse perform first? a. Check for a blood return i. This action of ensuring the IVC’s patency will not promote the resolution of the problem b. Elevate the extremity i. This will not promote a resolution of the problem—though elevation can help promote venous drainage and swelling reduction c. Discontinue the IV line i. Because the patient is exhibiting classic signs of phlebitis the IV line should immediately be discontinued to reduce the risk of thrombophlebitis and embolism d. Apply warm, moist heat i. This action could help alleviate symptoms, but will not alone resolve the problem 3. A nurse initiating a peripheral IV infusion punctures the skin and selected vein and observes blood return in the flashback chamber of the IV catheter. Which of the following actions should the nurse perform next? a. “Secure the catheter to the skin with a transparent dressing” i. NO. Securing is one of the last steps. Doing so before stabilizing could dislodge the IVC and/or cause harm to the client b. “Lower the catheter until it is almost flush with the skin” i. Lowering the angle before advancing slightly helps with full penetration of the wall vein and full entry into the lumen (making it easier to advance the catheter off of the stylet) c. “Advance the catheter about ¼ inch into the vein” i. NO. Advancing the IVC without lowering the angle risks puncturing the opposite wall of the vein! d. “Remove the stylet slowly from the lumen of the catheter” i. NO. Keep stylet in place until the catheter is positioned further within the vein 4. A nurse has just initiated a peripheral IV infusion of 5% dextrose in water. How often should the nurse plan to replace the primary infusion tubing? a. “q 24 hours” i. Replace q 24 hours when administering blood, blood products, or lipid emulsions b. “q 48 hours” i. Unless the solution wasn’t compatible with the current infusate/the tubing is compromised, there’s no need to change this frequently c. “q 72 hours” i. CDC recommends q 72 unless tubing has been contaminated, punctured or obstructed d. “q 108 hours” i. Waiting this long could put the patient at risk for infection, etc. 5. A nurse who has just initiated an IV infusion explains to the patient that complications are possible and that she will monitor the infusion regularly. The nurse should teach the patient that which of the following findings is an indication of early infiltration? a. “Moisture” i. Typically, damp dressing is due to a loose hub-tubing connection. If the tubing is secure moisture could be a late sign of infiltration…not an early one b. “Bruising” i. Bruising is not uncommon after venipuncture, since trauma to capillaries is can happen during insertion c. “Tingling” i. This is typical of an irritated/compromised nerve. An infiltration would have to be very severe to affect neurological function d. “Coolness” i. This is a classic sign of infiltration—the leakage of IV solution out of the vein (intravascular compartment) into the surrounding tissues ii. Other symptoms: 1. Swelling, pallor, and possibly tenderness 6. A nurse is removing an IVC from a patient whose IV infusion has been discontinued. Which of the following actions is appropriate? a. “Apply firm pressure over the vein” i. NO. This could cause pain unnecessarily b. “Leave the roller clamp slightly open” i. NO. Close the roller clamp to avoid spilling IV fluids c. “Pull the catheter straight back from the insertion site” d. “Lift the hub slightly upward and away from the skin” i. Changing the angle of the catheter could irritate the vein and risk post-infusion phlebitis 7. A nurse has just inserted a peripheral IVC for a continuous infusion. To secure the catheter, the nurse should a. “Leave the connection between the hub and tubing uncovered” i. Making it possible to replace tubing without removing dressing b. “Wrap tape around the circumference of the patient’s arm” i. NO. You risk impairing circulation c. “Tape the IVC’s hub securely to the patient’s skin” i. NO. This can exert undo pressure on the skin. Instead place a small gauze pad under the IVC hub to elevate it and avoid direct pressure d. “Place a piece of paper tape over the insertion site” i. NO. This would block visibility of the insertion site 8. Which is an important nursing action when converting an IV infusion to a saline lock? a. “Open the roller clamp of the primary infusion to prime the saline lock” i. Saline lock must be primed, but this is done with a separate syringe NOT from the original infusion line. b. “Apply pressure with a syringe to clear resistance in the IVC” i. Never apply pressure if you encounter resistance—this could place the patient at risk for an embolism c. “Attach secondary tubing to allow mobility” i. Piggybacking is an example of secondary tubing. A saline lock attaches to the extension tubing, not to secondary tubing d. “Flush the IVC to confirm patency” i. After priming the saline lock it’s essential to attach it to the extension tubing and to flush with normal saline to confirm patency 9. A patient in early stage renal failure is prescribed an infusion of 0.45% NaCl. This type of solution is appropriate because it a. “Pulls fluid from the cells and increases vascular volume” i. 0.45% NaCl is a hypotonic solution. This scenario would be played out with a hypertonic solution such as 10% dextrose b. “Dilutes extracellular fluid and rehydrates the cell” i. A hypotonic solution will move fluid into the cells, thus enlarging and rehydrating them c. “Replaces extracellular volume and maintains intravascular volume” i. An isotonic solution, like full strength NaCl, would replace extracellular fluid loss and maintain or expand intravascular volume d. “Draws fluid into blood vessels and reduces interstitial compartments” i. Infusing a hypertonic solution would yield this statement, as those draw fluid into the vessels by pulling them from the cells…thus increasing vascular volume
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University Of Alabama - Birmingham
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NUR 530 (NUR530)
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a nurse is discontinuing an iv infusion for which of the following reasons is it important to verify and document the integrity and condition
