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Ch. 15 AD
Terms in this set (22)
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.
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.
A nurse assesses a client who has a radial a 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 .
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"
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 .
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 degrees
d. Pain rating of 8 on a scale of 0-10
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 degrees
C) are signs of meningitis and would be reported to the primary health care provider immediately. The other findings important but do not require immediate intervention
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./test 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
Compartment syndrome is a condition in which increased tissue pressure in a confined anatomic space causes decreased blood flow to the areaA 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.
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
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.
A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site What action will the nurse take next?
a. Apply cold compresses to the IV site.
b. Elevate the extremity on a pillow
c. test Flush the catheter with normal saline.
d. Stop the infusion of intravenous fluids.
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.
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 cordHow 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"
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 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. don't need to manually calculate IV infusion rates with start 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
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.
A nurse prepares to insert a peripheral venous catheter in an older adultWhat 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
d. Place a washcloth between the skin and tourniquet .
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.
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."
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.
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."
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
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
At the first sign of phlebitis, the catheter will be removed and warm compresses used to relieve pain. The other options are not appropriate for this type of pain.
A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and " feeling warm.For which complication of this therapy will the nurse assess the client?
a. Allergic reaction
b. Bowel obstruction
c. Catheter lumen occlusion
Fever, abdominal pain, abdominal rigidity, and rebound tenderness may be present in the client who has peritonitis related to intraperitoneal therapy . Peritonitis is preventable by using strict aseptic technique in handling all equipment and infusion supplies . An allergic reaction would show other signs and symptoms. Bowel obstruction and catheter lumen occlusion can occur but would present clinically in different ways.
A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention will the nurse suggest to the management team to make the biggest impact on decreasing complications?
a. Initiate a dedicated team to insert access devices . b. Require additional education for all nurses.
c. Limit the use of peripheral venous access devices. d. Perform quality control testing on skin preparation products .
The Centers for Disease Control and Prevention recommends having a dedicated IV team to reduce complications, save money, and improve client satisfaction and outcomes . In-service education would always be helpful , but it would not have the same outcomes as an IV team. Limiting the use of various access devices may not be practical . The quality of skin preparation products is only one aspect of IV insertion that could contribute to infection .
A nurse prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of heparin. The pharmacy supplies a multidose vial of heparin with a concentration of 100 units / m * L . Which of the syringes shown below will the nurse use to draw up and administer the heparin ?
Always use a 10 mL syringe when flushing PICC lines because of smaller syringe creates higher pressure, which could rupture the lumen of the PICC. The PICC line would be assessed with a needleless syringe
A home care nurse prepares to administer intravenous medication to a client . The nurse assesses the site and reviews the client's chart prior to administering the medication and notes it to have been inserted 4 months ago. The site has no redness , warmth, or swelling and flushes easily. What action does the nurse take?
a. Notify the primary health care provider.
b. Administer the prescribed medication .
c. Discontinue the PICC
d. Switch the medication to the oral route .
A PICC that is functioning well without inflammation or infection may remain in place for months. Because the line shows no signs of complications , it is permissible to administer the IV antibiotic . There is no need to call the primary health care provider or to have the IV medication changed to an oral route.
A registered nurse (RN) occasionally delegates client care to licensed practical nurses (LPNs) or techniciansWhat information does the RN consider when delegating components of IV therapy? (Select all that apply.)
a . Each state's Nurse Practice Act will regulate who can perform care related to IVs .
b. The nurse would check the facility's Policies and Procedures manual.
c. The LPN's level of experience primarily guides the decision.
d Technicians cannot participate in any part of caring for IV infusions.
e. The RN remains accountable for all aspects of IV care and delegated actions
f. The Infusion Nurses Society has guidelines and standards of IV therapy competency.
ANS: A, B, E, F
The state Nurse Practice Act will have the information the RN fleeds to determine scope of practice, and in some states, LPNs and technicians are able to perform specific aspects of IV therapy. The nurse would also be familiar with facility policies and procedures regarding delegation of IV therapy. Amount of experience is not a criterion as LPNs and technicians can have their knowledge and skills verified. The nurse remains accountable for all aspects of IV therapy include what has been delegated. The Infusion Nurses Society has published guidelines and standards related to competency for IV therapy.
A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which common complications will the nurse assess? (Select all that apply.)
d. Excessive bleeding
ANS: A, C
Although the complication rate with PICCs is fairly low, the common complications are phlebitis, thrombophlebitis, and catheter-related bloodstream infection. Excessive bleeding, infiltration, and extravasation are not common complications. Pneumothorax does not occur.
A nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) universal bar-coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply.)
a. Unique facility identifier
b. Lot number related to the donor
c. Name of the client receiving blood
d. ABO group and Rh type of the donor
e. Blood type of the client receiving blood
f. Signature line for 2-person verification test
ANS: A, B, D
The ISBT universal bar-coding system includes four components : (1) the unique facility identifier, (2) the lot number relating to the donor , (3) the product code, and (4) the ABO group and Rh type of the donor. Positive identification by two qualified health care providers is essential although automated bar coding is acceptable in some care areas. However, a signature line is not required on the blood label.
A nurse assists with insertion a central vascular access device. nurse ensure are completed to prevent a catheter-related bloodstream infection? (Select all that apply.)
a. Include a review for the need of the device each day in the client's plan of care.
b. Remind the primary health care provider to perform hand hygiene prior to insertion if he or she forgets
c. Cleanse the preferred site with alcohol and let it dry completely before insertion.
d. Ask everyone in the room to wear a surgical mask during the procedure.
e. Plan to complete a sterile dressing change on the device every day.
f. Minimal client draping and barrier precautions as blood loss are minimal.
ANS: A, B, D
The central vascular access device bundle to prevent catheter-related bloodstream infections includes using a checklist during insertion, performing hand hygiene before inserting the catheter and anytime someone touches the catheter, using chlorhexidine to disinfect the skin at the site of insertionusing preferred sites, and reviewing the need for the catheter every day. The practitioner who inserts the device would wear sterile gloves, gown, and mask, and anyone in the room would wear a mask. Maximal barrier precautions are used which requires the client to be draped sterilely from head to toe. The initial dressing on a central vascular access device is changed in 24 hours. Gauze and tape dressings are changed every 48 hours and transparent membrane dressings are changed every 5 to 7 days.
A nurse prepares to insert a short peripheral venous catheter. What actions will the nurse take to use best practices? (Select all that apply.)
a. Choose a distal site on the client's nondominant arm.
b. Verify that the prescription is appropriate for peripheral infusion.
c. Place the venous catheter near an area of joint flexion.
d. Wear a surgical mask during the catheter insertion procedure.
e. Perform hand hygiene before inserting the catheter.
f. Limit unsuccessful attempts by up to three clinicians to one attempt each.
ANS: A, B, E
Best practices for the insertion of a short peripheral venous catheter include hand hygiene prior to the procedure, verification of the prescription for intravenous therapy and its appropriateness for infusion through a short peripheral catheter, and placement of the catheter in a distal site, away from an area of joint flexion and when possible in the client's nondominant arm. Surgical masks are needed for central venous catheter placement but not for short peripheral venous catheter placement. Unsuccessful attempts to insert the catheter should be limited to two per person and no more than four total
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