Module 13 Maintenance of IV Fluid Therapy

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Which of the following are part of maintenance care of a peripheral intravenous site? (Select all that apply.)

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Terms in this set (39)

Which of the following are part of maintenance care of a peripheral intravenous site? (Select all that apply.)

- changing the IV dressing
- ongoing assessment
- Changing IV tubing
-Change IV Fluids
- regulating IV flow rate

A confused elderly patient has pulled out her IV twice. The health care provider has ordered restraints and that the IV be restarted for the transfusion of packed red blood cells (PRBCs). Which factors in this situation may alter the rate of infusion? (Select all that apply.)

- Viscosity (thickness) and temperature of the infusion.
- Improperly placed restraints
- Manipulation of the IV catheter by the patient.

The nursing assistive personnel turned and repositioned the patient as requested. However, now the electronic infusion device is alarming. Which of the following situations is most likely to have set off the alarm?

The patient is lying on the tubing

Which of the following is an acceptable IV site in a child but not a routine site in adults?

Foot

A vital factor in the care of a peripheral IV infusion is the prevention of infection. Which of the following, if performed by the nurse, would indicate that the nurse requires further instruction in IV fluid therapy management? The nurse:

palpates the IV insertion site after the site is cleansed to verify vein location before needle insertion.

If a nurse fails to monitor a patient's intravenous (IV) infusion, what complications could develop? (Select all that apply.)

- the patient may experience infiltration
- The catheter may clot off.
- The patient may receive less than the prescribed amount of IV fluids.
- The patient may receive more than the prescribed amount of IV fluids.

Calculate the following problem. Remember to round off the answer to the nearest whole number, because fractions of a drop are to be avoided when calculating IV drip rates.Order: 1000 mL of D51/2NS (dextrose 5% in 0.45% sodium chloride) in 8 hoursAvailable: 1 liter of D51/2NS (dextrose 5% in 0.45% sodium chloride); IV macrodrip tubing 10 gtt per milliliterThe patient should receive _______ gtt per minute.

Calculate the following problem. Remember to round off the answer to the nearest whole number, because fractions of a drop are to be avoided when calculating IV drip rates.Order: 500 mL of D5W in 2 hoursAvailable: 500 mL of D5W; IV macrodrip tubing 15 gtt per milliliterThe patient should receive _______ gtt per minute.

Calculate the following problem. Remember to round off the answer to the nearest whole number, because fractions of a drop are to be avoided when calculating IV drip rates.Order: 500 mL of D5W in 5 hoursAvailable: Electronic infusion device; 500 mL of D5W, microdrip tubing (drop factor 60 gtt/mL)The electronic infusion device rate is _______ gtt per minute.

100

The nursing staff attended an in-service on IV fluid management with discussion on patient safety. Which of the following statements, if made by one of the staff, indicates further instruction is needed?"It is unnecessary to monitor infusion rates when an electronic infusion device is being used."The nurse has received an order to infuse an IV medication. Which of the following would be the safest choice of equipment to use?A smart pumpA patient has an order for the administration of 1000 mL of 0.9% normal saline at 100 mL/hr. The nurse begins the infusion at 0900. At noon the nurse notices that 500 mL has infused. Of the following options, which should be the nurse's highest priority action?A smart pumpA patient has received 1000 mL of IV fluid in 2 hours. The patient has dyspnea, tachycardia, crackles in the lungs, and peripheral edema. What is the nurse's priority action at this time?Assess the patient for symptoms of fluid volume overload.A nurse working in the emergency room has elected to use macrodrip IV tubing. For which patient would this be most appropriate?Slow infusion to KVO and notify health care provider.Remember to round off the answer to the nearest whole number, because fractions of a drop are to be avoided when calculating IV drip rates.A patient is to receive 1000 mL of 0.45% normal saline over 12 hours. The nurse begins the infusion at 0800. Four hours later, the nurse notes there is 750 mL left in the IV bag. The nurse recalculates the flow rate. The nurse should set the electronic infusion device at _______mL/hr.94The nurse hangs 1000 mL of 0.9% normal saline at 0900. The ordered rate is 80 mL/hr and is infusing with microdrip tubing and an EID. The nurse would expect to hang a new IV bag at approximately at what time? _______(in military time—remember 2400 is midnight)2130A nurse working in the emergency room has elected to use macrodrip IV tubing. For which patient would this be most appropriate?A hypotensive adult trauma victim with cool, clammy skin.The nurse performed hand hygiene and applied clean gloves to perform an intravenous (IV) tubing change. Which step(s) described in the following was missed or performed incorrectly?Remove IV dressing covering catheter hub and slow rate of infusion to keep-vein-open (KVO) by regulating the roller clamp. Fill drip chamber of old tubing, remove IV container from IV pole, and remove old tubing from the solution. Place insertion spike of new tubing into the old fluid container opening and hang it on the IV pole. Fill tubing rapidly with solution, creating air bubbles in the tubing. Turn roller clamp to the "off" position on the new tubing and remove as much air as possible. Turn roller clamp on the old tubing to the "off" position. Stabilize hub of the catheter, disconnect the old tubing from the catheter hub, and quickly insert adapter of new tubing into catheter hub. Open roller clamp on new tubing, and regulate IV drip according to health care provider's orders. Secure tubing with a piece of tape. Place label with date and time on tubing below drip chamber. Discard old tubing and used supplies, remove gloves, and perform hand hygiene.Failing to close the roller clamp on the new tubing before inserting it into the fluid container.The patient has an order to infuse gentamicin (Garamycin) 500 mg IV in 50 mL sodium chloride at a rate of 100 mL/hr every 4 hours. The patient does not have an order for continuous fluids, and therefore the medication is infused with primary tubing and the peripheral access device is saline locked between doses. Which of the following actions could cause contamination or increase the risk of infection? (Select all that apply.)- When changing tubing, the nurse disconnects the old tubing and attempts to insert the adapter of the new tubing without removing the protective cap. - The nurse changes the primary intermittent tubing set every 96 hours. - When it is time to hang a new dose of gentamicin (Garamycin), the nurse connects the tubing to the injection port using the same needleless adapter that has been hanging on the IV pole for 4 hours without a protective cover.The electronic infusion device (EID) is alarming after changing the bag of IV fluids on a continuous infusion. What could be the possible cause(s)? (Select all that apply.)- The roller clamp is in the "off" position. - air is present in the tubingThe nursing students are studying in a group. Which of the following statements, if made by a nursing student, indicates further instruction is needed?"The bag of fluids should be changed when there is approximately 100 mL of solution left in the bag to avoid disruption in fluid therapy to the patient."The nurse is changing IV fluids. She has performed hand hygiene and applied clean gloves. The nurse hung the new bag of fluids on the IV pole, removed the protective cover of the tubing port, removed the spike from the old bag, and accidentally touched the spike with her hand. Which action should be taken at this time?Obtain a new IV tubing set, remove the protective cover of the spike and insert it into the tubing port of the IV bag she just hung. Prime the tubing.Identify the situations in which a peripheral intravneous (IV) line dressing requires changing. (Select all that apply.)- The patient's IV dressing got wet during bathing. - There is blood underneath the transparent dressing from movement of the catheter.Which of the following indicate that the infusion needs to be temporarily discontinued, the catheter removed, and the IV relocated? (Select all that apply.)- The student nurse cleans the site with a povidone-iodine swab in a concentric circle and immediately applies a new dressing to protect against infection. - The student nurse applies sterile gloves and removes the old dressing, being careful to avoid dislodging the catheter. - After completing the dressing change, the student nurse documents in the patient's chart the presence of swelling, coolness, blanching, and complaints of pain at the insertion site.What is the rationale for avoiding taping over the connection of the tubing to the hub?- Small amount of purulent drainage is at insertion site; redness is noted. - Insertion site is pale, cool to touch, and extremity edematous.The nurse checks the identity of the patient, performs hand hygiene, and applies clean gloves. The nurse removes the old dressing, cleans the site with CHG solution in a back-and-forth motion, and allows the site to dry. The nurse applies a new manufactured catheter stabilization device, applies a transparent dressing, secures the tubing with tape, and labels the dressing with date and time of dressing change. The nurse discards used equipment and performs hand hygiene. The student nurse observing the nurse change the peripheral IV dressing correctly identifies actions the nurse should have performed. The student nurse is correct in identifying which two actions?- Access to the catheter hub is needed when changing tubing. - To stabilize the catheter when removing the old dressing.What is the rationale for avoiding taping over the connection of the tubing to the hub?Access to the catheter hub is needed when changing tubing.At 0800, a 1000 mL bag of D5 1/2NS is hung. The flow rate is 125 mL per hour and the drop factor is 60 gtt per mL. At 1200 (noon), 550 mL is left. What action should the nurse take to make sure the IV completes on time?Increase the rate to 138 mL/hrSolve the following problem. Remember to round off the answer to the nearest whole number, because fractions of a drop are to be avoided when calculating IV drip rates.Order: Ringer's lactate 1000 mL to be given within 12 hours.Available: 1 liter (1000 mL) Ringer's lactate; infusion tubing labeled 15 gtt per mL, _______ gtt per minute.21 gtt/minSolve the following problem. Remember to round off the answer to the nearest whole number, because fractions of a drop are to be avoided when calculating IV drip rates.A patient has an IV of 1000 mL normal saline to infuse at 50 mL per hour. It takes _______ hours for the patient to receive this infusion.20 hoursSolve the following problem. Remember to round off the answer to the nearest whole number, because fractions of a drop are to be avoided when calculating IV drip rates.Order: Normal saline 1000 mL to infuse at 150 mL per hour.Available: 1 liter (1000 mL) normal saline; infusion tubing labeled 15 gtt per mL, _______ gtt per minute.38 gtt/minInstructions: Solve the problem. Remember to round off the answer to the nearest whole number, because fractions of a drop are to be avoided when calculating IV drip rates.Order: 1000 mL 0.9% NaCl with 20 mEq KCL to run 8 hours.Available: 1 liter (1000 mL) 0.9% NaCl with 20 mEq KCL added; infusion tubing labeled 15 gtt per mL, _______ gtt per minute.31 gtt/minA nursing student has initiated and regulated an IV in the skills lab but is now assigned to a patient in a clinical setting. The patient has an IV of 0.9% normal saline infusing at 50 mL/hr. Which of the following indicates correct understanding regarding managing IV fluid administration?When using microdrip tubing, milliliters per hour equals gtt per minute.The nurse is determining if any of the patients require a peripheral IV dressing change. The date is 2/22 and the time is 0900. The agency uses a commercially engineered catheter stabilization device with its own transparent dressing. Which of the following patients would require a peripheral dressing change? (Select all that apply.) A patient:- with the peripheral IV dressing dated 2/17, 1000. - with a wet peripheral IV dressing after bathing. - whose manufactured stabilization device is loose.The nursing assistive personnel reports to the nurse that the patient appears to be very short of breath. The nurse assesses the patient and determines the patient is experiencing fluid volume excess (FVE). The nurse notes that 500 mL of IV fluids have infused in the last hour, rather than the prescribed 50 mL/hr. What action should the nurse take first?Slow the rate of infusionSolve the following problem. Remember to round off the answer to the nearest whole number, because fractions of a drop are to be avoided when calculating IV drip rates.Order: 1000 mL to be infused for 12 hours on micro drip, _______ gtt per minute.83 gtt/minA student nurse is changing the intravenous (IV) line tubing of a patient's peripheral IV. Which action, if made by the student nurse, indicates that further instruction is needed? The student nurse: (Select all that apply.)- connects the new tubing to the patient and then removes any air bubbles. - opens the clamp so that the flow rate is wide open to reduce the time of priming the tubing.A patient has been admitted with heart failure. The health care provider's orders state to administer normal saline at 50 mL per hour. An hour later, the nurse finds that 150 mL have infused. What priority assessments should the nurse make? (Select all that apply.)- Auscultate lungs for crackles. - Check pulse for tachycardia. - Assess respiratory pattern for evidence of dyspnea. - Inspect lower extremities for edema.