Chapter 13Infusion Therapy My Nursing Test Banks

Chapter 13Infusion Therapy

MULTIPLE CHOICE

1.A client is scheduled for a peripherally inserted central catheter in a few days. However, the client needs intravenous fluids infused immediately. Which of the following veins should the nurse avoid when starting the intravenous infusion now?

1.

Accessory cephalic vein

2.

Basilic vein

3.

Cephalic vein

4.

Median vein

ANS: 3

The cephalic vein should be reserved for a midline or peripherally inserted central catheter since it is located near the antecubital fossa. The other veins are appropriate for IV starts.

PTS: 1 DIF: Apply REF: Anatomy and Physiology; Percutaneous Catheters

2.The tubing on a clients intravenous infusion administration set is not long enough to support the clients ambulation needs. Which of the following can the nurse do to assist this client?

1.

Apply a stopcock.

2.

Add an extension set.

3.

Use a filter.

4.

Attach a needleless access device.

ANS: 2

An extension set is used to add length and additional medication ports to primary tubing. A stopcock is used to direct the flow of fluid in the intravenous line. A filter is used to eliminate air and particles that should not be infused into the client. A needleless access device is used at medication ports to add a layer of safety.

PTS: 1 DIF: Apply REF: Box. 13-1 Add-On Devices for Infusion Therapy

3.An intravenous catheter has been inserted over a clients antecubital joint. Which of the following should the nurse do to ensure the clients comfort and the usefulness of the catheter?

1.

Use an arm board to keep the arm straight.

2.

Wrap gauze around the insertion site.

3.

Place a gauze dressing over the insertion site.

4.

Apply a wrist restraint to keep the arm straight.

ANS: 1

If an intravenous catheter has to be placed over a joint, the nurse should use an arm board to immobilize the site, prolong the life of the intravenous line, and decrease mechanical phlebitis.

PTS: 1 DIF: Apply REF: IV Procedure Special Considerations

4.After preparing a clients skin for insertion of an intravenous catheter, the nurse accidentally touches the skin site with an uncovered finger. Which of the following should the nurse do?

1.

Cleanse the skin again.

2.

Apply clean gloves and continue.

3.

Locate another vein to access.

4.

Continue with the insertion of the catheter.

ANS: 1

Once the site is prepared, the nurse should not touch the site unless sterile gloves are worn. If the site is touched by unprotected skin, the nurse should cleanse the skin again. The nurse should not apply clean gloves and continue. The nurse does not need to locate another vein to access. The nurse should not continue with the insertion of the catheter since this can lead to an infection of the site.

PTS:1DIF:ApplyREF:IV Complications

5.Which of the following should the nurse assess to determine if a clients intravenous infusion has infiltrated?

1.

A blood return

2.

Size of extremity

3.

Presence of pain

4.

Presence of a temperature

ANS: 2

If infiltration is suspected, the nurse should compare both arms. The dominant arm should be a bit larger, but a significant difference in size could mean infiltration. A blood return may still be visible with an infiltrated intravenous line. A lack of a blood return does not always mean the cannula is no longer in the vein since some cannulas can collapse when aspirating from them. Presence of pain could be due to the solution type. Hypertonic solutions cause more pain. The presence of a temperature could mean a variety of health conditions and not necessarily an infiltration.

PTS: 1 DIF: Apply REF: Infiltration

6.A client is diagnosed with an extravasation of a intravenous medication. Which of the following should the nurse do to assist this client?

1.

Remove the catheter and apply heat.

2.

Place the extremity lower than the level of the heart.

3.

Keep the catheter intact until an antidote is administered.

4.

Apply ice over the site until the swelling subsides.

ANS: 3

If extravasation occurs, the cannula should not be removed until it is determined if an antidote exists. If an antidote exists, instill it through the cannula into the area of extravasation. Then the cannula can be removed and the extremity elevated. Heat or cold should be applied according to the medication which extravasated.

PTS:1DIF:ApplyREF:Extravasation

7.A client is complaining of numbness and tingling around the intravenous infusion catheter. Which of the following should the nurse do?

1.

Apply heat.

2.

Remove the cannula.

3.

Elevate the extremity.

4.

Slow the intravenous infusion rate.

ANS: 2

Complaints of numbness and tingling around the intravenous infusion catheter could indicate nerve damage. The nurse should remove the cannula, document the complaint, and notify the physician if the symptoms do not resolve after the cannula is removed. Applying heat will not be helpful. Elevating the extremity is not indicated for suspected nerve damage. Slowing the intravenous infusion rate will not reduce the likelihood of nerve damage and should not be done.

PTS:1DIF:ApplyREF:Nerve Damage

8.A client is prescribed to receive a medication diluted in 50 mL of 0.9% Normal Saline four times a day. The nurse realizes that this type of administration is considered:

1.

continuous.

2.

direct injection.

3.

patient-controlled.

4.

intermittent.

ANS: 4

Intermittent infusion means that a small volume of fluid is infused in a short amount of time. A continuous infusion means that a large volume of fluid is infused over hours and days. Patient-controlled infusion provides the client with the ability to deliver a pain medication. Direct injection provides the medication directly into the bloodstream for immediate results.

PTS:1DIF:AnalyzeREFharmacology

9.A client has an implanted port for medication administration. Which of the following should the nurse use when administering medications through this port?

1.

Use a noncoring needle.

2.

Use an 18 gauge needle.

3.

Apply heat to the site prior to administering medication.

4.

Flush the port after administering medications.

ANS: 1

An implanted port contains a reservoir that is accessed with a noncoring needle. The nurse should not use an 18 gauge needle. The nurse does not need to apply heat to the site prior to administering medication. The port does not need to be flushed after administering medications.

PTS:1DIF:ApplyREF:Implanted Ports

10.A client is receiving total parenteral nutrition. Which of the following interventions are appropriate for this client?

1.

Provide the infusion at the maximum rate.

2.

Do not use a pump for infusing.

3.

Measure weights daily.

4.

Assess blood glucose levels every week.

ANS: 3

Interventions for a client receiving total parenteral nutrition include measuring the clients weight daily. The infusion should be started slowly and gradually increase to the maximum infusion rate. The infusion should be administered with a pump. Blood glucose levels should be assessed every 6 hours during the first week of receiving this infusion.

PTS: 1 DIF: Apply REF: Total Parenteral Nutrition

11.A client has the blood type of O+. Which of the following types of blood can the client receive if a transfusion is needed?

1.

A+

2.

B+

3.

O-

4.

AB+

ANS: 3

A client with the blood type of O+ can receive either O+ or O- blood. A client who has the blood type of O+ cannot receive A+, B+, or AB+ blood.

PTS: 1 DIF: Understand REF: Table 13-4 Blood Types

MULTIPLE RESPONSE

1.A client is prescribed to receive an intravenous infusion of a hypertonic solution. The nurse realizes that which of the following solutions are considered hypertonic? (Select all that apply.)

1.

0.45% Normal Saline

2.

Dextrose 5% and 0.9% Normal Saline

3.

Dextrose 5% and water

4.

Dextrose 10% and water

5.

Ringers lactate

6.

Dextran 5% in water

ANS: 2, 4

Hypertonic solutions cause fluid to move out of the cells, resulting in shrinkage of the cells. Hypertonic solutions include Dextrose 5% and 0.9% Normal Saline and Dextrose 10% and water. Ringers lactate is an isotonic solution. The solutions of 0.45% Normal Saline and Dextrose 5% and water are hypotonic. Dextran 5% in water is a plasma extender.

PTS: 1 DIF: Analyze REF: Table 13-1 Common IV Therapy Solutions

2.A client is prescribed to receive an infusion of intralipid 10%. Which of the following should the nurse do when providing this infusion? (Select all that apply.)

1.

Use a filter.

2.

Infuse with 0.9% Normal Saline.

3.

Hang for 24 hours.

4.

Administer for up to 16 hours.

5.

Measure strict output.

6.

Limit oral fluids.

ANS: 1, 4

When administering an infusion of intralipids 10%, the nurse should administer it with a filter. The nurse should not add medications and should not hang for more than 16 hours. The infusion should not be provided with 0.9% Normal Saline. The infusion should not be delivered for 24 hours. Strict output and oral fluid restriction is not necessary when providing intralipids to a client.

PTS: 1 DIF: Apply REF: Table 13-1 Common IV Therapy Solutions

3.The nurse is having difficulty accessing a clients vein to insert an intravenous catheter. Which of the following interventions can be used to assist in this process? (Select all that apply.)

1.

Use a tourniquet.

2.

Dangle the arm off the side of the bed.

3.

Apply a warm towel.

4.

Have the client pump the fist.

5.

Apply a heating pad.

6.

Warm the catheter in the microwave.

ANS: 1, 2, 3, 5

To promote venous distention, the nurse can use a tourniquet, dangle the arm off the side of the bed, apply a warm towel, and apply a heating pad. Having the client pump the fist will increase vasospasm. The catheter should not be warmed in the microwave since this could adversely affect the functioning.

PTS: 1 DIF: Apply REF: Box 13-2 Selecting a Vein

4.The nurse suspects that a client has developed phlebitis from an intravenous catheter when which of the following is assessed? (Select all that apply.)

1.

Redness

2.

Cool skin over the intravenous site

3.

Warmth over the intravenous site

4.

Elevated body temperature

5.

Hard palpable cord along the vein track

6.

Blanching of the skin

ANS: 1, 3, 4, 5

Evidence of phlebitis from an intravenous catheter includes redness, warmth over the intravenous site, pain, elevated body temperature, and a hard palpable cord along the vein track. Cool skin over the intravenous site and blanching of the skin are assessment findings for an infiltration.

PTS: 1 DIF: Analyze REF: Phlebitis

5.The nurse is making a visit to a client prescribed to receive intravenous therapy in the home. Which of the following should the nurse assess when preparing to administer intravenous medication to this client? (Select all that apply.)

1.

Food

2.

Telephone

3.

Sufficient electrical outlets

4.

Location of throw rugs

5.

Clean work area

6.

Home cleanliness

ANS: 2, 3, 5, 6

When administering intravenous medications in the home, the nurse needs to evaluate the home for cleanliness, place for supplies, clean work area, refrigeration, pets, sufficient electrical outlets, no insects or parasites, telephone, and batteries and supplies. The nurse does not need to assess for food or the location of throw rugs.

PTS: 1 DIF: Apply REF: Special Considerations

SHORT ANSWER

1.How many drops per minute should the nurse regulate a clients intravenous infusion of Lactated Ringers 125 mL per hour with a drop factor of 15 drops per mL?

ANS:

31 drops per minute

125 mL/60 minutes 15 gtts/mL = 31 gtts/min

PTS: 1 DIF: Apply REF: Administration of IV Solutions

2.A client is prescribed to receive 1000 mL of 0.9% Normal Saline in an 8-hour time frame. Using a microdrip set, how many drops per minute will the infusion run?

ANS:

125 gtts/min

RAT: 1000 mL/8 hours = 125 mL/hr; 125 mL/60 minutes 60 gtts/mL = 125 gtts/min

PTS: 1 DIF: Apply REF: Administration of IV Solutions

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