Copyright © 2022 Med C
f. Tetany
ANS: A, E
A client receiving total parenteral nutrition is at risk for metabolic alkalosis. Signs and symptoms of
metabolic alkalosis include positive Chvostek sign, normal or low blood pressure, increased heart rate,
skeletal muscle weakness, possible tetany and seizures, and anxiety and irritability.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Acid-base imbalances, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
5. A nurse is planning care for a client who is lethargic and confused. The client‘s arterial blood
gas values are pH 7.30, PaO 2 96 mm Hg, PaCO 2 43 mm Hg, and HCO 3 19 mEq/L (19
mmol/L). Which questions would the nurse ask the client and spouse when developing the
plan of care? (Select all that apply.)
a. ―Are you taking any antacid medications?‖
b. ―Is your spouse‘s current behavior typical?‖
c. ―Do you drink any alcoholic beverages?‖
d. ―Have you been participating in strenuous activity?‖
e. ―Are you experiencing any shortness of breath?‖
ANS: B, C, D
This client‘s symptoms of lethargy and confusion are related to a state of metabolic acidosis. The nurse
would ask the client‘s spouse or family members if the client‘s behavior is typical for him or her, and
establish a baseline for comparison with later assessment findings. The nurse would also assess for
alcohol intake because alcohol can cause metabolic acidosis.
Excessive and strenuous activity can lead to overproduction of hydrogen ions. The other options are
not causes of metabolic acidosis.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Acid-base imbalance, Acidosis MSC: Client Needs Category: Psychosocial Integrity
Chapter 15: Concepts of Infusion Therapy
Ignatavicius: Medical-Surgical Nursing, 11th
Edition
MULTIPLE CHOICE
1. A nurse is caring for a client who has just had a central venous access line inserted. What
action will the nurse take next?
a. Begin the prescribed infusion via the new access.
b. Ensure that an x-ray is completed to confirm placement.
c. Check medication calculations with a second RN.
d. Make sure that the solution is appropriate for a central line.
ANS: B
A central venous access device, once placed, needs an x-ray confirmation of proper placement before it
is used. The bedside nurse would be responsible for beginning the infusion once placement has been
verified. Any IV solution can be given through a central line.
, Copyright © 2022 Med C
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: Infusion therapy, Vascular access device
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
2. A nurse assesses a client who has a radial artery catheter. Which assessment will the nurse
complete first?
a. Amount of pressure in fluid container
b. Date of catheter tubing change
c. Type of dressing over the site
d. Skin color and capillary refill
ANS: D
An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased perfusion
to the extremity. Assessment of color, warmth, sensation, capillary refill time, and distal pulses (if
appropriate) are assessments for circulation distal to the catheter site. The nurse would note that there
is enough pressure in the fluid container to keep the system flushed, and would check to see whether
the catheter tubing needs to be changed. However, these are not assessments of greatest concern. The
type of dressing over the site would be noted and most likely prescribed by policy.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Infusion therapy, Vascular access device
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A nurse teaches a client who is being discharged home with a peripherally inserted central
catheter (PICC). Which statement will the nurse include in this client‘s teaching?
a. ―Avoid carrying your grandchild with the arm that has the central catheter.‖
b. ―Be sure to place the arm with the central catheter in a sling during the day.‖
c. ―Flush the peripherally inserted central catheter line with normal saline daily.‖
d. ―You can use the arm with the central catheter for most activities of daily living.‖
ANS: A
A properly placed PICC (in the antecubital fossa or the basilic vein) allows the client considerable
freedom of movement. Clients can participate in most activities of daily living; however, heavy lifting
can dislodge the catheter or occlude the lumen. Although it is important to keep the insertion site and
tubing dry, the client can shower. The device is flushed with heparin.
DIF: Applying TOP: Integrated Process: Teaching/Learning
KEY: Infusion therapy, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
4. A nurse is caring for a client who is receiving an epidural infusion for pain management.
Which assessment finding requires immediate intervention from the nurse?
a. Redness at the catheter insertion site
b. Report of headache and stiff neck
c. Temperature of 100.1° F (37.8° C)
d. Pain rating of 8 on a scale of 0-10
ANS: B
, Copyright © 2022 Med C
Complications of epidural therapy include infection, bleeding, leakage of cerebrospinal fluid, occlusion of
the catheter lumen, and catheter migration. Headache, neck stiffness, and a temperature higher than 101° F
(37.8° C) are signs of meningitis and would be reported to the primary health care provider immediately. The
other findings are important but do not require immediate intervention.
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: Infusion therapy, Complications
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
5. A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which
assessment finding is of greatest concern?
a. The catheter has been in place for 20 hours.
b. The client has poor vascular access in the upper extremities.
c. The catheter is placed in the proximal tibia.
d. The client‘s left lower extremity is cool to the touch.
ANS: D
Compartment syndrome is a condition in which increased tissue pressure in a confined anatomic space
causes decreased blood flow to the area. A cool extremity can signal the possibility of this syndrome.
All other findings are important; however, the possible development of compartment syndrome
requires immediate intervention because the client could require amputation of the limb if the nurse
does not correctly assess and respond to this perfusion problem.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Infusion therapy, Complications
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
6. A nurse is assessing clients who have intravenous therapy prescribed. Which assessment
finding for a client with a peripherally inserted central catheter (PICC) requires immediate
attention?
a. The initial site dressing is 3 days old.
b. The PICC was inserted 4 weeks ago.
c. A securement device is absent.
d. Upper extremity swelling is noted.
ANS: D
Upper extremity swelling could indicate infiltration, and the PICC will need to be removed. The initial
dressing over the PICC site would be changed within 24 hours. This does not require immediate
attention, but the swelling does. The dwell time for PICCs can be months or even years. Securement
devices are being used more often now to secure the catheter in place and prevent complications such
as phlebitis and infiltration. The IV lacking one does not take priority over the client whose arm is
swollen.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Infusion therapy, Vascular access device
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. A nurse assesses a client‘s peripheral IV site, and notices edema and tenderness above the site.
, Copyright © 2022 Med C
What action will 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.
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 would 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.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Infusion therapy, Complications
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
8. While assessing a client‘s peripheral IV site, the nurse observes a streak of red along the vein
path and palpates a 1.5 inch (4-cm) venous cord. How will 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‖
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.
DIF: Understanding
TOP: Integrated Process: Communication and Documentation
KEY: Infusion therapy, Complications
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
9. A new nurse is caring for a client receiving drug therapy via a smart pump. What statement by
the new nurse demonstrates the need for more instruction on this technology?
a. ―I don‘t need to manually calculate IV infusion rates with smart pumps.‖
b. ―Responding to IV pump alarms is a high priority for client safety.‖
c. ―The hospital can preprogram the pumps for high-alert drug limits.‖
d. ―These pumps have a system to prevent fluids from free-flowing into the client.‖
ANS: A
The ―smarter‖ the pump is the more programming needs to occur and errors can happen and systems
can fail. Using a programmable pump does not relieve the nurse of his or her responsibility to monitor
the infusion site and rates and ensure the client is receiving the fluids or medications as prescribed. The
Joint Commission continues to include responding to alarms as a National Patient Safety Goal. Pumps
can be preprogrammed so that upper limits exist for high-alert drugs. All electronic infusion devices
have some mechanism for preventing free flow of fluids if the cassette or tubing is removed from the
pump.
DIF: Analyzing TOP: Integrated Process: Teaching/Learning
f. Tetany
ANS: A, E
A client receiving total parenteral nutrition is at risk for metabolic alkalosis. Signs and symptoms of
metabolic alkalosis include positive Chvostek sign, normal or low blood pressure, increased heart rate,
skeletal muscle weakness, possible tetany and seizures, and anxiety and irritability.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Acid-base imbalances, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
5. A nurse is planning care for a client who is lethargic and confused. The client‘s arterial blood
gas values are pH 7.30, PaO 2 96 mm Hg, PaCO 2 43 mm Hg, and HCO 3 19 mEq/L (19
mmol/L). Which questions would the nurse ask the client and spouse when developing the
plan of care? (Select all that apply.)
a. ―Are you taking any antacid medications?‖
b. ―Is your spouse‘s current behavior typical?‖
c. ―Do you drink any alcoholic beverages?‖
d. ―Have you been participating in strenuous activity?‖
e. ―Are you experiencing any shortness of breath?‖
ANS: B, C, D
This client‘s symptoms of lethargy and confusion are related to a state of metabolic acidosis. The nurse
would ask the client‘s spouse or family members if the client‘s behavior is typical for him or her, and
establish a baseline for comparison with later assessment findings. The nurse would also assess for
alcohol intake because alcohol can cause metabolic acidosis.
Excessive and strenuous activity can lead to overproduction of hydrogen ions. The other options are
not causes of metabolic acidosis.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Acid-base imbalance, Acidosis MSC: Client Needs Category: Psychosocial Integrity
Chapter 15: Concepts of Infusion Therapy
Ignatavicius: Medical-Surgical Nursing, 11th
Edition
MULTIPLE CHOICE
1. A nurse is caring for a client who has just had a central venous access line inserted. What
action will the nurse take next?
a. Begin the prescribed infusion via the new access.
b. Ensure that an x-ray is completed to confirm placement.
c. Check medication calculations with a second RN.
d. Make sure that the solution is appropriate for a central line.
ANS: B
A central venous access device, once placed, needs an x-ray confirmation of proper placement before it
is used. The bedside nurse would be responsible for beginning the infusion once placement has been
verified. Any IV solution can be given through a central line.
, Copyright © 2022 Med C
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: Infusion therapy, Vascular access device
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
2. A nurse assesses a client who has a radial artery catheter. Which assessment will the nurse
complete first?
a. Amount of pressure in fluid container
b. Date of catheter tubing change
c. Type of dressing over the site
d. Skin color and capillary refill
ANS: D
An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased perfusion
to the extremity. Assessment of color, warmth, sensation, capillary refill time, and distal pulses (if
appropriate) are assessments for circulation distal to the catheter site. The nurse would note that there
is enough pressure in the fluid container to keep the system flushed, and would check to see whether
the catheter tubing needs to be changed. However, these are not assessments of greatest concern. The
type of dressing over the site would be noted and most likely prescribed by policy.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Infusion therapy, Vascular access device
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A nurse teaches a client who is being discharged home with a peripherally inserted central
catheter (PICC). Which statement will the nurse include in this client‘s teaching?
a. ―Avoid carrying your grandchild with the arm that has the central catheter.‖
b. ―Be sure to place the arm with the central catheter in a sling during the day.‖
c. ―Flush the peripherally inserted central catheter line with normal saline daily.‖
d. ―You can use the arm with the central catheter for most activities of daily living.‖
ANS: A
A properly placed PICC (in the antecubital fossa or the basilic vein) allows the client considerable
freedom of movement. Clients can participate in most activities of daily living; however, heavy lifting
can dislodge the catheter or occlude the lumen. Although it is important to keep the insertion site and
tubing dry, the client can shower. The device is flushed with heparin.
DIF: Applying TOP: Integrated Process: Teaching/Learning
KEY: Infusion therapy, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
4. A nurse is caring for a client who is receiving an epidural infusion for pain management.
Which assessment finding requires immediate intervention from the nurse?
a. Redness at the catheter insertion site
b. Report of headache and stiff neck
c. Temperature of 100.1° F (37.8° C)
d. Pain rating of 8 on a scale of 0-10
ANS: B
, Copyright © 2022 Med C
Complications of epidural therapy include infection, bleeding, leakage of cerebrospinal fluid, occlusion of
the catheter lumen, and catheter migration. Headache, neck stiffness, and a temperature higher than 101° F
(37.8° C) are signs of meningitis and would be reported to the primary health care provider immediately. The
other findings are important but do not require immediate intervention.
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: Infusion therapy, Complications
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
5. A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which
assessment finding is of greatest concern?
a. The catheter has been in place for 20 hours.
b. The client has poor vascular access in the upper extremities.
c. The catheter is placed in the proximal tibia.
d. The client‘s left lower extremity is cool to the touch.
ANS: D
Compartment syndrome is a condition in which increased tissue pressure in a confined anatomic space
causes decreased blood flow to the area. A cool extremity can signal the possibility of this syndrome.
All other findings are important; however, the possible development of compartment syndrome
requires immediate intervention because the client could require amputation of the limb if the nurse
does not correctly assess and respond to this perfusion problem.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Infusion therapy, Complications
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
6. A nurse is assessing clients who have intravenous therapy prescribed. Which assessment
finding for a client with a peripherally inserted central catheter (PICC) requires immediate
attention?
a. The initial site dressing is 3 days old.
b. The PICC was inserted 4 weeks ago.
c. A securement device is absent.
d. Upper extremity swelling is noted.
ANS: D
Upper extremity swelling could indicate infiltration, and the PICC will need to be removed. The initial
dressing over the PICC site would be changed within 24 hours. This does not require immediate
attention, but the swelling does. The dwell time for PICCs can be months or even years. Securement
devices are being used more often now to secure the catheter in place and prevent complications such
as phlebitis and infiltration. The IV lacking one does not take priority over the client whose arm is
swollen.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Infusion therapy, Vascular access device
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. A nurse assesses a client‘s peripheral IV site, and notices edema and tenderness above the site.
, Copyright © 2022 Med C
What action will 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.
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 would 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.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Infusion therapy, Complications
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
8. While assessing a client‘s peripheral IV site, the nurse observes a streak of red along the vein
path and palpates a 1.5 inch (4-cm) venous cord. How will 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‖
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.
DIF: Understanding
TOP: Integrated Process: Communication and Documentation
KEY: Infusion therapy, Complications
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
9. A new nurse is caring for a client receiving drug therapy via a smart pump. What statement by
the new nurse demonstrates the need for more instruction on this technology?
a. ―I don‘t need to manually calculate IV infusion rates with smart pumps.‖
b. ―Responding to IV pump alarms is a high priority for client safety.‖
c. ―The hospital can preprogram the pumps for high-alert drug limits.‖
d. ―These pumps have a system to prevent fluids from free-flowing into the client.‖
ANS: A
The ―smarter‖ the pump is the more programming needs to occur and errors can happen and systems
can fail. Using a programmable pump does not relieve the nurse of his or her responsibility to monitor
the infusion site and rates and ensure the client is receiving the fluids or medications as prescribed. The
Joint Commission continues to include responding to alarms as a National Patient Safety Goal. Pumps
can be preprogrammed so that upper limits exist for high-alert drugs. All electronic infusion devices
have some mechanism for preventing free flow of fluids if the cassette or tubing is removed from the
pump.
DIF: Analyzing TOP: Integrated Process: Teaching/Learning
