Chapter 15: Concepts of Infusion Therapy
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. 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 KEY:
Infusion therapy, Client safety MSC: Client Needs Category:
Physiological Integrity: Pharmacological and Parenteral Therapies
,2. A nurse prepares to insert a peripheral venous catheter in an older adult. What action
will 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.
ANS: D
To protect the client’s skin, the nurse will place a washcloth or the client’s gown
between the skin and tourniquet. The other interventions are methods to distend the
vein but will not protect the client’s skin.
DIF: Understanding TOP: Integrated Process: Nursing Process:
Implementation KEY: Infusion therapy, Older adult MSC: Client
Needs Category: Physiological Integrity: Reduction of Risk Potential
3. A nurse delegates care to an assistive personnel (AP). Which statement will 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 client’s bath.”
d. “Use a plastic bag to cover the extremity with the device.”
ANS: D
The nurse will ask the AP 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
or bath with a vascular device. The nurse will 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 AP.
, DIF: Applying TOP: Integrated Process: Communication and Documentation
KEY: Infusion therapy, Delegation MSC: Client Needs Category:
Physiological Integrity: Basic Care and Comfort
4. A nurse teaches a client who is prescribed a central vascular access device and is
transferring to a skilled facility for long-term treatment. Which statement will the
nurse include in this client’s teaching?
a. “You will need to wear a sling on your arm while the device is in place.”
b. “There is no risk of infection because sterile technique will be used during
insertion.”
c. “Ask all providers to vigorously clean the connections prior to accessing the
device.”
d. “You will not be able to take a bath with this vascular access device.”
ANS: C
The nurse would actively engage the client in the prevention of catheter-related
bloodstream infections and taught to remind all providers to perform hand hygiene
and vigorously clean connections prior to accessing the device. The other statements
are incorrect.
DIF: Applying TOP: Integrated Process: Teaching/Learning
KEY: Infusion therapy, Infection control MSC: Client
Needs Category: Physiological Integrity: Reduction of Risk Potential
5. A nurse is caring for a client with a peripheral vascular access device who is
experiencing pain, redness, and swelling at the site. After removing the device, what
action will the nurse take to relieve pain?
a. Administer topical lidocaine to the site.
b. Place warm compresses on the site.
c. Administer prescribed oral pain medication.
d. Massage the site with scented oils.
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. 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 KEY:
Infusion therapy, Client safety MSC: Client Needs Category:
Physiological Integrity: Pharmacological and Parenteral Therapies
,2. A nurse prepares to insert a peripheral venous catheter in an older adult. What action
will 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.
ANS: D
To protect the client’s skin, the nurse will place a washcloth or the client’s gown
between the skin and tourniquet. The other interventions are methods to distend the
vein but will not protect the client’s skin.
DIF: Understanding TOP: Integrated Process: Nursing Process:
Implementation KEY: Infusion therapy, Older adult MSC: Client
Needs Category: Physiological Integrity: Reduction of Risk Potential
3. A nurse delegates care to an assistive personnel (AP). Which statement will 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 client’s bath.”
d. “Use a plastic bag to cover the extremity with the device.”
ANS: D
The nurse will ask the AP 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
or bath with a vascular device. The nurse will 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 AP.
, DIF: Applying TOP: Integrated Process: Communication and Documentation
KEY: Infusion therapy, Delegation MSC: Client Needs Category:
Physiological Integrity: Basic Care and Comfort
4. A nurse teaches a client who is prescribed a central vascular access device and is
transferring to a skilled facility for long-term treatment. Which statement will the
nurse include in this client’s teaching?
a. “You will need to wear a sling on your arm while the device is in place.”
b. “There is no risk of infection because sterile technique will be used during
insertion.”
c. “Ask all providers to vigorously clean the connections prior to accessing the
device.”
d. “You will not be able to take a bath with this vascular access device.”
ANS: C
The nurse would actively engage the client in the prevention of catheter-related
bloodstream infections and taught to remind all providers to perform hand hygiene
and vigorously clean connections prior to accessing the device. The other statements
are incorrect.
DIF: Applying TOP: Integrated Process: Teaching/Learning
KEY: Infusion therapy, Infection control MSC: Client
Needs Category: Physiological Integrity: Reduction of Risk Potential
5. A nurse is caring for a client with a peripheral vascular access device who is
experiencing pain, redness, and swelling at the site. After removing the device, what
action will the nurse take to relieve pain?
a. Administer topical lidocaine to the site.
b. Place warm compresses on the site.
c. Administer prescribed oral pain medication.
d. Massage the site with scented oils.
