Chapter 7. Nursing Care of Patients Receiving Intravenous Therapy My Nursing Test Banks

Chapter 7. Nursing Care of Patients Receiving Intravenous Therapy

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. The health care provider is planning to discontinue total parenteral nutrition for a patient who has been receiving it for 3 weeks after an episode of severe gastrointestinal (GI) bleeding. What patient care order should the nurse anticipate?
a. Place the patient on clear liquids for 1 week.
b. Start tube feedings tid via nasogastric tube.
c. Sodium-restricted diet with high-protein snacks bid.
d. Taper PN rate and introduce regular feedings slowly.
____ 2. The nurse is preparing to insert an intravenous (IV) catheter in a newly admitted patient. Which area should the nurse use first for this catheter?
a. Hand
b. Forearm
c. Upper arm
d. Antecubital space
____ 3. The IV infusion pump for a patient receiving an IV therapy begins to alarm and displays occlusion. When the silence button is pushed, the alarm quickly resumes. Which action should the nurse take first?
a. Notify the physician.
b. Check for kinking of the tubing or a closed clamp.
c. Decrease the rate to 10 mL/hr, and flush the line with 1 mL of heparin solution.
d. Turn off the IV solution, and gently flush the line with 3 mL of saline flush solution.
____ 4. Assessment of blood glucose levels is prescribed every 6 hours for a patient who is receiving parenteral nutrition (PN). The patient asks why this is necessary. Which response by the nurse is most appropriate?
a. We have to monitor your glucose because the physician prescribed it.
b. When people receive PN, they develop mild diabetes, which needs to be well regulated.
c. PN contains a lot of sugar. We monitor blood glucose to be sure it doesnt get too high.
d. There is a lot of sugar in the solution, which can increase the risk for rebound hypoglycemia.
____ 5. The nurse notes that a patients central venous access device (CVAD) infusion site gauze dressing is saturated with blood. What should the nurse do?
a. Change the dressing.
b. Reinforce the dressing with a gauze pad.
c. Notify the physician to change the dressing.
d. Apply a transparent dressing over the gauze.
____ 6. An angiocatheter site in a patients left forearm has become red and tender. What should the nurse do first?
a. Check for a blood return.
b. Remove the angiocatheter.
c. Apply a warm compress over the insertion site.
d. Run the IV solution at a slightly faster rate to encourage sluggish circulation.
____ 7. As soon as the nurse begins to insert an IV catheter in the patients antecubital space, a hematoma forms at the site. What should the nurse do first?
a. Remove the catheter and call for help.
b. Remove the catheter and apply pressure to the site.
c. Remove the catheter and insert a new one in the same site.
d. Finish threading the catheter quickly and apply a pressure dressing and tape.
____ 8. The nurse is preparing heparin to use as a flush for a patients IV infusion site. For which type of site is the nurse providing care?
a. Peripheral access device
b. Intermittent access device
c. CVAD
d. Intermittent piggyback device
____ 9. A patient in an outpatient oncology clinic is going to have a peripherally inserted central catheter (PICC) line placed and wants to know what that means. What is the best response by the nurse?
a. A PICC line is a percutaneous IV core catheter.
b. A PICC line is just a regular IV, but an extra-small catheter is used to prevent vein irritation.
c. A PICC line is a catheter that is inserted into your jugular vein and ends in the central circulation.
d. A PICC line is an IV device that is inserted into your arm and ends in the circulation near your heart.
____ 10. An IV infusion is not running. The insertion site looks normal. Which action should the nurse take to try to get it to run again?
a. Reposition the extremity.
b. Place gentle pressure on the bag of solution.
c. Flush the catheter with 1 to 2 mL of heparin flush solution.
d. Flush the catheter with 1 to 2 mL of normal saline solution.
____ 11. A patient is in the intensive care unit with acute renal failure secondary to septic shock and is receiving IV fluids of 0.9% NaCl at 125 mL/hr. The patient develops crackles in the lungs, distended neck veins, 1+ pitting edema in the feet, and a 4-pound weight gain from the previous day. What nursing diagnosis is most appropriate for this situation?
a. Excess fluid volume
b. Decreased cardiac output
c. Ineffective tissue perfusion: peripheral
d. Imbalanced nutrition: greater than body requirements
____ 12. An IV insertion site begins to leak, and the tape over the site is wet. What should the nurse do first?
a. Reduce the IV flow rate.
b. Call the physician to report the problem.
c. Remove the dressing from the IV site, and observe the insertion site.
d. Slowly increase the speed of the IV drip, and watch the site carefully for increased leaking of IV solution.
____ 13. The nurse needs to dilate a patients vein prior to inserting an IV catheter. Which technique should the nurse use to dilate the patients vein?
a. Elevate the extremity for 5 minutes.
b. Apply an alcohol swab for 60 seconds.
c. Apply a cool compress for 15 minutes.
d. Apply a tourniquet for up to 3 minutes.
____ 14. Upon entering a patients room, the licensed practical nurse (LPN) notes a white precipitate forming in the IV tubing at the site of a piggybacked antibiotic. What should the nurse do first?
a. Stop the infusion.
b. Notify the physician.
c. Call the pharmacy to see whether this is an expected reaction.
d. When the infusion is complete, remove the tubing, and send it to the laboratory for analysis.
____ 15. A patients IV fluids are infusing too quickly despite adjustments made to the flow rate. Which approach should the nurse consider to slow the flow rate of a gravity solution?
a. Opening the roller clamp
b. Flushing the cannula with saline solution
c. Raising the level of the solution container
d. Flexing the extremity above the insertion site
____ 16. A patient is prescribed an IV infusion of a hypertonic solution. Which fluid shift should the nurse expect to occur with this type of infusion?
a. Fluid moves from the plasma into the cells.
b. Fluid moves from the venous circulation into the interstitial space.
c. Fluid moves from the interstitial space into the venous circulation.
d. Fluid moves from the arterial circulation into the venous circulation.
____ 17. The nurse suspects a patient receiving IV therapy is experiencing fluid overload. Which assessment should the nurse perform first?
a. Check the patients weight.
b. Assess lung sounds for crackles.
c. Observe the patients feet for edema.
d. Inspect the insertion site for infiltration.
____ 18. A patient is prescribed IV fluid to replace electrolytes and expand plasma volume. Which type of fluid will the nurse provide to the patient?
a. Isotonic solution
b. Dextrose solution
c. Hypotonic solution
d. Hypertonic solution
____ 19. When assessing a patient with an IV line in the right arm, the LPN notices that the skin near the infusion site is taut and cool, and when the arm is lowered, it appears to swell. What should the nurse consider is occurring with this patients IV access site?
a. Infection
b. Embolism
c. Infiltration
d. Venous spasm
____ 20. At a monthly staff meeting, the nurse manager announces that all central line insertion and dressing kits will now come bundled with 2% chlorhexidine gluconate for site preparation and cleansing. Which evidence best supports this decision?
a. The use of 2% chlorhexidine gluconate reduces hospital costs by 7%.
b. Chlorhexidine gluconate (CHG) is the preferred prep solution of choice based on scientific evidence.
c. The company that supplies IV and central line catheter equipment has recently changed the product bundling to include 2% chlorhexidine gluconate.
d. The chief of surgery is interested in performing a direct comparison study examining infection rates associated with long-term access devices as they are related to length of time the catheters are in place.
____ 21. The nurse is preparing to flush a patients intermittent IV catheter. Why is the nurse flushing this catheter?
a. To open an occluded catheter
b. To provide electrolyte replacement
c. To prevent the formation of emboli
d. To ensure the patency of the catheter
____ 22. The nurse is preparing to administer a bolus IV medication through a patients saline lock. Which action should the nurse take immediately before providing the patient with this medication?
a. Calculate the drip rate.
b. Prepare the saline flush.
c. Cleanse the hub for 15 seconds.
d. Check the order for the medication.
____ 23. A patient is prescribed to receive two units of packed red blood cells. When preparing for this patients infusion of blood, which type of IV solution should the licensed practical nurse/licensed vocational nurse LPN/LVN select?
a. 0.9% Normal Saline
b. 0.45% Normal Saline
c. Dextrose 5% and water
d. Dextrose 5% and 0.9% Normal Saline
____ 24. A patient is prescribed to receive a continuous infusion of IV fluids. When preparing to place the catheter, the nurse notes that the client has a dialysis fistula in the right arm and had a left breast mastectomy three years prior. What should the nurse do?
a. Place the catheter in the left hand.
b. Place the catheter in the right foot.
c. Place the catheter in the right hand.
d. Ask the physician where to place the catheter.
____ 25. After preparing the skin for IV catheter placement, the nurse decides that the vein needs to be palpated before introducing the catheter. How should the nurse perform this action?
a. Palpate the vein with the clean gloved hand.
b. Palpate the vein and then cleanse the skin again.
c. Apply sterile gloves before palpating the cleansed skin site.
d. Apply skin cleanser to the gloved fingertip before palpating the vein.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____ 26. The nurse analyzes the fluid volume status of assigned patients. Which patients are most likely to need continuous IV therapy? (Select all that apply.)
a. A 45-year-old woman with a broken humerus
b. A patient with pitting edema and lung crackles
c. A 16-year-old girl with anorexia who has been repeatedly purging
d. A 3-year-old who has had frequent diarrhea and vomiting for 3 days
e. An 85-year-old man with Alzheimers disease who refuses to eat or drink
____ 27. The nurse is concerned that a patient is developing complications from peripheral IV therapy. For which systemic complication should the nurse assess the patient? (Select all that apply.)
a. Phlebitis
b. Infiltration
c. Septicemia
d. Air embolism
e. Extravasation
f. Fluid overload
____ 28. The nurse is preparing to start a peripheral IV infusion. Which technique should the nurse use to help ensure success with the venipuncture? (Select all that apply.)
a. Use a tourniquet to dilate the vein.
b. Elevate the extremity to promote venous return.
c. Apply a warm compress prior to site preparation.
d. Lower the head of the bed to reduce cardiac output.
e. Encourage the patient to open the hand and lay it flat on the bed.
f. Push the skin toward the intended puncture site to prevent rolling.
____ 29. The nurse is planning to insert an IV catheter into a patient with severe upper extremity edema. Which actions should the nurse take to ensure the catheter is placed appropriately? (Select all that apply.)
a. Select a catheter that is 2 inches in length.
b. Use alcohol to cleanse the site before insertion.
c. Bring three tourniquets to the patients bedside.
d. Displace edema to visualize the patients veins.
e. Apply sterile gloves before beginning the procedure.
Completion
Complete each statement.

30. A patient is prescribed an IV antibiotic medication that is 100 mg in 50 mL D5W to be infused over 20 minutes. The infusion set delivers 15 gtt per mL. How many drops of medication per minute should the infusion set deliver to the patient?

31. A patient is to receive an IV liter of normal saline over 6 hours. To deliver the fluid, how many mL per hour should the nurse set the pump?

Chapter 7. Nursing Care of Patients Receiving Intravenous Therapy
Answer Section

MULTIPLE CHOICE

1. ANS: D
D. When PN therapy is started, the rate is increased gradually to the prescribed rate to help prevent hyperglycemia. When it ends, the rate is gradually decreased to prevent hypoglycemia. A. Clear liquids do not provide enough protein. B. Tube feedings use the GI system the same as oral feedings. C. A sodium-restricted diet with high-protein snacks is not indicated.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

2. ANS: A
A. Hand veins are used first if long-term IV therapy is expected. This allows each successive venipuncture to be made proximal to the site of the previous one, which eliminates the passage of irritating fluids through a previously injured vein and discourages leakage through old puncture sites. B. The forearm can be used if hand veins are not available or if previous catheters were placed into hand veins. C. D. The upper arm and antecubital space are not ideal locations for IV catheter placement.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

3. ANS: B
B. A kink in the tubing or closed clamp is often the reason for occlusion and can be easily remedied. C. D. Flushing tubing can dislodge a clot into systemic circulation. A. There is no reason to notify the physician.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

4. ANS: C
C. Because of the high glucose concentration of PN, the patient is at risk for infection and blood glucose disturbances. Ongoing assessments include blood glucose levels according to institution policy. A. A physician may have prescribed the monitoring, but it is not a satisfactory answer for the patient. B. Glucose should return to normal after PN is discontinued, so the patient should not be told he has diabetes unless a diagnosis has been made. D. Rebound hypoglycemia can occur after PN is discontinued.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

5. ANS: A
A. If saturated with blood, the gauze dressing over a CVAD infusion site should be changed. B. Reinforcing the dressing with a gauze pad is not sufficient for this access site. C. The nurse can change the dressing. D. A transparent dressing should not be placed over a soiled gauze dressing.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

6. ANS: B
B. Redness and tenderness indicate infection. The catheter must be removed and a new one placed. A, C, and D do not address infection.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

7. ANS: B
B. If a hematoma forms at the site of an IV catheter, remove the catheter and apply pressure to the site. A. The situation is not dire and calling for help is not necessary. C. A new catheter should not be inserted in the same site as a hematoma. D. The vein should not be used if a hematoma forms.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

8. ANS: C
C. Heparin is an anticoagulant and is recommended for flushing CVADs. Heparin is a medication and may be incompatible with other medications. A. B. D. Heparin is not used to flush peripheral access devices, intermittent access devices, or intermittent piggyback devices.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Analysis

9. ANS: D
D. A PICC line is a long catheter that is inserted in the arm and terminates in the central circulation. This device is used when therapy will last more than 2 weeks or when the medication is too caustic for peripheral administration. C. This describes a percutaneous central catheter. A. B. These do not describe a PICC line.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

10. ANS: A
A. Repositioning the extremity may move the catheter enough to restore flow. B. C. D. These actions could cause a clot to be dislodged into the general circulation and should not be taken.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

11. ANS: A
A. Crackles, distended neck veins, edema, and weight gain are signs of fluid excess. B. C. The patient may have decreased cardiac output and ineffective tissue perfusion, but the patients symptoms are those of fluid excess. D. IV fluids of 0.9% do not supply nutrition.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

12. ANS: C
C. A site can leak for many reasons, so the first nursing action is to further assess for a cause. A. B. These actions might be indicated based on the assessment findings but would not be the first action. D. The nurse would never speed the IV drip without a physician order.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

13. ANS: D
D. A tourniquet will impede venous flow and dilate the vein. A. C. Elevation or a cool compress will make a vein less visible. B. Alcohol cleanses the skin.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

14. ANS: A
A. Solids should never be infusedthey could cause an embolism. The infusion should be stopped immediately to prevent this from happening. B. C. After the IV is stopped, the pharmacy and physician should be notified. D. Tubing may be sent for analysis according to agency policy.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

15. ANS: D
D. Flexing the extremity may compress the vessel and slow the rate. A. B. C. Raising the level of the solution, opening the clamp, and flushing a cannula may speed flow rate.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

16. ANS: C
C. Hypertonic solutions pull water into the venous circulation through osmosis. A. B. These describe actions of hypotonic solutions. D. Fluid does not move directly from arterial to venous circulation.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Analysis

17. ANS: B
B. Crackles result from excess fluid backing up into the lungs. Breathing is a priority. A. C. Weight and edema may also indicate fluid excess, but are not as important as breathing. D. Infiltration at the insertion site is unrelated to fluid balance.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

18. ANS: D
D. Hypertonic fluids pull fluid from the interstitial space into venous circulation, expanding plasma volume. Lactated Ringers solution is a hypertonic solution that also replaces electrolytes. A. Isotonic solutions are not generally given to replace electrolytes. B. C. Hypotonic and Dextrose solutions will shrink plasma volume.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Analysis

19. ANS: C
C. These are symptoms of infiltration. A. Warmth and redness accompany infection. D. Pain is present with venous spasm. B. Embolism will cause systemic symptoms.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Analysis

20. ANS: B
B. Evidence supporting a clinical change in practice should be related to improved patient outcomes and should be based on high-level evidence. A. C. D. These options do not reflect an improvement in patient outcomes.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Analysis

21. ANS: D
D. Flushing maintains catheter patency. A. C. Flushing will not prevent formation of emboli and may even cause emboli when done inappropriately such as in an attempt to open an occluded catheter. B. Flushing uses a small amount of solution and will not replace lost fluids or provide electrolytes.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Analysis

22. ANS: C
C. When using a saline lock for a bolus medication, the hub should be scrubbed for 10 to 15 seconds with friction before each access to prevent infection. A. The medication is going to be bolused. There is no reason to calculate a drip rate. B. The saline flush should have been prepared by this time. D. The medication order should have been checked by this time.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

23. ANS: A
A. According to the American Association of Blood Banks, blood component administration sets can be primed only with 0.9% sodium chloride solution. B. C. D. Blood component administration sets are not to be primed with any solution other than 0.9% normal saline.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

24. ANS: D
D. The patient has contraindications for placement of the catheter in either arm. A. C. Limbs for IV catheter placement are avoided because of dialysis shunt placement and mastectomies. The only approach for the nurse to take is to ask the physician in which limb the IV catheter can be safely placed. B. The lower extremities are not routinely used for IV catheter placement.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

25. ANS: C
C. The nurse should not repalpate the site after prepping it. If the site needs to be repalpated after cleaning, sterile gloves must be worn to perform this step. A. This could cause an infection. B. This could cause excessive skin irritation. D. This is incorrect technique and should not be done.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

MULTIPLE RESPONSE

26. ANS: C, D, E
C. D. E. Very young and very old people have lower body water content and are therefore at higher risk for dehydration and need IV therapy. A patient who purges is losing excess fluid and electrolytes. A. A 45-year-old patient with a broken bone is not at risk for fluid loss. B. A patient with edema and crackles is fluid overloaded and does not need continuous IV fluids.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Analysis

27. ANS: C, D, F
C, D, and F are systemic complications, because they involve many body systems. A. B. E. These are local complications, limited to the IV site and surrounding area.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

28. ANS: A, C
A. C. Warm compresses may help dilate the vein. A tourniquet will help dilate and stabilize the vein. B. The extremity should be placed in a dependent position. D. Reduced cardiac output will not optimize venipuncture. E. The patient should be encouraged to open and close the fist a couple of times to pump blood to the extremity. F. The skin should be pulled away from the intended site to prevent rolling.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

29. ANS: A, C, D
A. C. D. When needing to insert an IV catheter into an edematous limb, the nurse should use a catheter that is 2 inches in length; the nurse should use the multiple tourniquet technique, which employs 3 tourniquets, and press down on the tissue to displace the edema and visualize the patients veins. B. Alcohol is not used to cleanse the insertion site. E. Sterile gloves are not needed to insert the catheter.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

COMPLETION

30. ANS:
38 gtt/min

50 mL 15 gtt = 38 gtt /min
20 minutes 1 mL
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

31. ANS:
167 mL/hr

1000 mL = 167 mL/hour
6 hours
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

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