Module 11 IV Fluid Therapy

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The nurse is caring for a patient with a diagnosis of heart failure. With which of the following IV solutions should the nurse monitor this patient most closely?
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Terms in this set (43)
Which of the following sites should be avoided when initiating an intravenous infusion? (Select all that apply.)- The left arm of a patient who has a history of a left-sided mastectomy. - An area of venous bifurcation or palpation of valves. - side of paralysisA busy medical-surgical unit is short staffed. It is time for routine vital signs. One patient's electronic infusion device is alarming because the IV bag is empty, and another patient has new orders for initiating an IV infusion. Which task(s) may be delegated to the NAP? (Select all that apply.)- Getting the IV tray of IV supplies - Having the assistive personnel inform the nurse when IV fluids are low in volume - Taking routine vital signsA patient has been receiving intravenous (IV) antibiotics and as a result has had several IV site locations. What action can the nurse take to promote venous distention in the patient? (Select all that apply.)- Rub or stroke the patient's arm. - Apply a warm pack to the arm for several minutes.At what angle should an IV catheter puncture the skin and vein during insertion in a middle-aged adult?10 to 30 degree angleWhen should the tourniquet be released a second time during the procedure for insertion of a peripheral intravenous device?After a "flashback" of blood is observed and the catheter has been advanced off the stylet.The nurse is preparing an IV infusion before initiating an IV. Which of the following is a correct action performed by the nurse?After spiking the bag of IV fluids, the nurse fills the drip chamber 1/3 to 1/2 full and primes the tubing, making sure there are no bubbles.The nurse is preparing an IV infusion before initiating an IV. The nurse removes the protective sheath covering the tubing insertion spike and accidentally touches the spike. What is the nurse's best action at this time?Discard IV tubing and obtain a new one.The nurse is assessing the patient for signs and symptoms of fluid volume excess. Which of the following would indicate the patient is experiencing this complication and should be reported? (Select all that apply.)- Shortness of breath and crackles in lungs. - Elevated blood pressure and edema.Which of the following would be consistent with infiltration? (Select all that apply.)- Swelling around insertion site. - Pain with increasing infiltration. - cool to touchWhich of the following would be consistent with phlebitis? (Select all that apply.)- pain - rednessAn elderly patient is receiving 0.9% normal saline at 125 mL per hour. The nursing assistive personnel (NAP) reports the patient is complaining of feeling short of breath. The nurse determines the patient is experiencing fluid volume excess. What other symptoms would lead the nurse to this conclusion? (Select all that apply.)- crackles in lungs - peripheral edema - dyspneaThe nurse notices failure of flow in the drip chamber with the roller clamp open and an absence of swelling at the insertion site. What should the nurse do? (Select all that apply.)- check for kink in IV tubing - determine latency by aspirating for blood returnWhich of the following situations indicates discontinuation of peripheral intravenous (IV) access? (Select all that apply.)- The electronic infusion pump keeps alarming, indicating "occlusion" on its screen, and the nurse is unable to flush the IV. - The patient's arm is swollen and cool to the touch; the patient complains of pain at the IV site. - The patient is being discharged to home on oral (PO) medications.The student nurse is watching the staff nurse discontinue a peripheral IV. The staff nurse removes the catheter and then looks at it. The student asks the nurse what she is looking for. What would be a correct response?"I am inspecting the catheter for intactness."What is the primary danger related to a broken catheter tip?embolusThe nurse is discontinuing peripheral IV access. Which of the following steps, if performed by the nurse, requires correction?With dry gauze or an alcohol swab held over the site, apply light pressure and withdraw the catheter by using a slow, steady movement with the hub at a 10- to 30-degree angle. Apply pressure to the site for 1 to 2 seconds by using a dry, sterile gauze pad.Which of the following demonstrates the best documentation of discontinuation of an IV?1030 20 Gauge 1 inch (2.5 cm) catheter removed from left forearm. Catheter tip intact. Site without redness, swelling, or bleeding. T. Rodriguez, RN.Which of the following situations indicates peripheral IV access could be discontinued (provided the health care provider has given the corresponding order)? (Select all that apply.) The patient:- Has an arm that is swollen and cool to the touch and complains of pain at the IV site. - Who has been receiving IV fluids for fluid maintenance is drinking fluids well and electrolytes are within normal limits. - Is complaining of pain at the IV site and there is absence of a blood return. - Is being discharged to home on oral (PO) meds.The nurse is preparing the IV for infusion. The nurse has checked the IV solution using the six rights of medication administration. The nurse checked the solution for clarity and expiration date. Which of the following steps, if performed by the nurse, require correction?The nurse checks the length of tubing and the drip chamber to make sure that both are filled with fluid and that no air is remaining.In which of the following situations would it be acceptable to allow the IV infusion (IV access) to continue?IV is infusing but at a slower rate than ordered.Which of the following IV solutions would be infused for the patient who has been vomiting and is requiring fluid replacement?0.9% sodium chlorideThe nursing instructor has been observing nursing students initiate an IV infusion. Which action(s), if made by the nursing student, indicate(s) that further instruction is needed? (Select all that apply.) The nursing student:- Cleans the insertion site with chlorhexidine solution in a back-and-forth motion for 30 seconds; allows the area to dry; then, while wearing gloves, palpates the vein before inserting the catheter at a 10- to 30-degree angle. - Applies the tourniquet, cleans the site, allows it to dry, performs the venipuncture, looks for blood return, advances the catheter off the stylet, applies pressure above the insertion site, connects the tubing, starts the infusion, and releases the tourniquet. - Removes gloves to tape and apply the transparent dressing over the intravenous site. Tapes tubing to transparent dressing.The nurse is preparing to document insertion of the IV in accordance with the health care provider's orders for normal saline at 100 mL per hour. Which of the following should the nurse include in documentation of the procedure? (Select all that apply.)- Number of attempts at insertion. - When infusion was begun and at what rate. - Size and type of catheter or needle. - Location of insertion site. - Patient's response. - Type of fluid.Upon discontinuing peripheral intravenous access, the nurse notes the catheter tip is missing. What action should the nurse take?Notify the healthcare provider immediatelyWhich of the following actions fail to follow practices of infection control, therefore placing either the nurse or patient at risk? (Select all that apply.)- Unable to obtain a flashback of blood, the nurse withdraws the catheter and needle and reinserts it at a deeper angle. - The nurse uses a needle when aspirating for a blood return to assess for patency.A trauma patient is received in the emergency room. Which size catheter should the nurse select to initiate the IV?18 gaugeA 4-year-old child was recently admitted to the hospital with orders for an IV to be started. The nurse prepares the IV infusion and primes the tubing, applies a tourniquet, selects a vein in the antecubital space, releases the tourniquet, applies gloves and cleans the site with chlorhexidine, reapplies the tourniquet, performs the venipuncture, obtains a blood return, advances the 24-gauge catheter off the stylet, applies pressure above the insertion site, releases the tourniquet, connects the tubing, and begins the infusion. The nurse then secures the catheter with tape and a dressing, adjusts the flow rate, and labels the dressing. Which action made by the nurse was incorrect?Site selectionThe nurse is performing a routine physical assessment on a patient with heart failure. The nurse finds the following data: Patient is alert and oriented, face flushed, lung sounds with rhonchi, respirations slightly labored at a rate of 28, heart rate 98, blood pressure 140 over 92, abdomen soft with bowel sounds present, clear yellow urine in bedside drainage bag of Foley catheter, and +2 edema of lower extremities. The patient has an IV of normal saline infusing at 125 mL per hour in the left forearm without redness at the IV site. The patient denies any complaints of pain. The nurse discontinues the IV, notifies the health care provider, raises the head of the bed, and monitors the patient's vital signs. Which of these nursing actions is wrong?Discontinuing IVThe student nurse is preparing to initiate an IV on a 36-year-old patient who is to receive an IV infusion for fluid maintenance. At this time, surgery is unanticipated. Which size catheter should the nursing student select?22 gaugeA 4-year-old child was recently admitted to the hospital and has orders for an intravenous (IV) line to be started. Which of the following is an acceptable IV insertion site for a child?The forearmThe nurse is informing the patient of actions that may be taken to promote venous distention. Which statement, if made by the patient, indicates further instruction is needed? (Select all that apply.)- "I've seen other nurse's tap the vein multiple times, maybe that will work." - "I need to keep my arm elevated for 10 to 20 minutes."A 48-year-old man has to have his IV restarted. It is currently located in his left lower forearm. He has a history of renal failure and has a shunt located in his right arm for dialysis. Which of the following is an appropriate site for IV relocation?The left arm, proximal to the previous IV site.Which of the following would be an appropriate site for placement of an IV?The patient's nondominant forearm.