NUR 172 EXAM 2- IV THERAPY
HONDROS QUESTIONS & DETAILED
ANSWERS
WHO recommendations - correct answer ✔✔Wash hands(b4&after) when doing any FOLEY
care.
No Acrylic Nails
Nails are to be no longer than 1/4 inch
Wash hands for 15-30 seconds
NO JEWLERY
Causes of Hematoma
TX - correct answer ✔✔Poor venipuncture technique
Patients taking steroids or anticoagulants/ASA
TX: direct pressure
Elevate extremity
Ice/cold pack
Hematoma - correct answer ✔✔Infiltration of blood in the tissues at the venipuncture site
S/S: swelling and discomfort at IV SITE
TX of Fluid volume overload (pulmonary edema)
S/S - correct answer ✔✔S/S: Crackles
Blood tinged Sputum
, SOB
Low pulse/Ox
TX: IM Lasix, Daily weights, fluid restrictions, Oxygen, slow IV rate or KVO or STOP it.
infiltrate - correct answer ✔✔Common complication; when IV fluid happens to make its way
outside the vein. This is why we check IV sites Q2-4H
S/S: cool, pale, edematous skin with pain
Tx: Heat/Cold compress, take IV out, check facility(MD ORDER) protocol, elevate extremity,
continue to monitor
Vesicant - correct answer ✔✔A fluid/ medication that can cause injury or even death to tissue if
leaked outside the vein
Examples of vesicants - correct answer ✔✔-Calcium Chloride
-Calcium Gluconate
-Contrast
-Dextrose 10%
-Vancomycin
-Potassium Chloride
Extravasation - correct answer ✔✔infiltration of vesicant type medication
S/S: looks like Infiltration but, blisters develop and the skin starts to slough off.
Tx: STOP infusion IMMEDIATELY
Check for antidote before removing IV, check with Pharmacists for directions with heat or cold
or elevation of extremity, Monitor Patient closely.
HONDROS QUESTIONS & DETAILED
ANSWERS
WHO recommendations - correct answer ✔✔Wash hands(b4&after) when doing any FOLEY
care.
No Acrylic Nails
Nails are to be no longer than 1/4 inch
Wash hands for 15-30 seconds
NO JEWLERY
Causes of Hematoma
TX - correct answer ✔✔Poor venipuncture technique
Patients taking steroids or anticoagulants/ASA
TX: direct pressure
Elevate extremity
Ice/cold pack
Hematoma - correct answer ✔✔Infiltration of blood in the tissues at the venipuncture site
S/S: swelling and discomfort at IV SITE
TX of Fluid volume overload (pulmonary edema)
S/S - correct answer ✔✔S/S: Crackles
Blood tinged Sputum
, SOB
Low pulse/Ox
TX: IM Lasix, Daily weights, fluid restrictions, Oxygen, slow IV rate or KVO or STOP it.
infiltrate - correct answer ✔✔Common complication; when IV fluid happens to make its way
outside the vein. This is why we check IV sites Q2-4H
S/S: cool, pale, edematous skin with pain
Tx: Heat/Cold compress, take IV out, check facility(MD ORDER) protocol, elevate extremity,
continue to monitor
Vesicant - correct answer ✔✔A fluid/ medication that can cause injury or even death to tissue if
leaked outside the vein
Examples of vesicants - correct answer ✔✔-Calcium Chloride
-Calcium Gluconate
-Contrast
-Dextrose 10%
-Vancomycin
-Potassium Chloride
Extravasation - correct answer ✔✔infiltration of vesicant type medication
S/S: looks like Infiltration but, blisters develop and the skin starts to slough off.
Tx: STOP infusion IMMEDIATELY
Check for antidote before removing IV, check with Pharmacists for directions with heat or cold
or elevation of extremity, Monitor Patient closely.
