Flashcards in Central Lines TPN Deck (54)
The nurse is caring for a patient receiving antineoplastic medications intravenously. The nurse discovers that the intravenous site is red, edematous, and painful. The nurse knows that antineoplastic medications are vesicant medications and documents that the patient has experienced which of the following events?
When a vesicant medication infiltrates the tissue, this is called an extravasation. Occlusion refers to a thrombus or fibrin sheath that impedes the flow of IV fluids. Phlebitis occurs with redness surrounding the vein, and extravasation leads to trauma within the vein
Established standards for routine replacement of peripheral IV catheters and intravenous administration sets have recommended a maximum of _____ hours to reduce IV fluid contamination and prevent catheter site complications.
Established standards for routine replacement of peripheral IV catheters and intravenous administration sets have recommended a maximum of 96 hours to reduce IV fluid contamination and prevent catheter site complications.
While assessing the patient, the nurse recognizes that special caution should be taken with the IV infusion because of fluid volume excess when the nurse notes the presence of which condition?
a. Poor skin turgor
b. Crackles in the lungs
c. Decreased blood pressure
d. Dry skin and mucous membranes
The nurse needs to specifically prevent air emboli that may result from IV therapy. What should the nurse make sure to do to prevent air emboli?
a. Use a needleless system.
b. Prime the tubing completely.
c. Check for medication compatibility.
d. Select a larger-gauge needle or catheter.
Prime the infusion tubing by filling it with IV solution. Be certain that the tubing is clear of air and air bubbles. Large air bubbles can act as emboli. A needleless system does not specifically prevent the introduction of air emboli. Medication incompatibility may lead to crystallization of the medication and may cause emboli to form from precipitate. It will not lead, however, to air embolism. Catheter size does not contribute to emboli formation.
Which of the following steps is necessary when a patient is prepared for IV insertion?
a. Shaving the hair from the site
b. Selecting a proximal site in an extremity
c. Applying a tourniquet 4 to 6 inches above the selected site
d. Vigorously taping and massaging the selected vein
Apply a flat tourniquet around the arm, above the antecubital fossa or 4 to 6 inches (10 to 15 cm) above the proposed insertion site. Do not shave the area. Shaving may cause microabrasions and may predispose to infection. Use the most distal site in the nondominant arm, if possible. Vigorous friction and multiple taping of the veins, especially in older adults, may cause hematoma and/or venous constriction.
What should be the next action by the nurse, once an over-the-needle catheter (ONC) has been inserted through the skin and into the vein?
a. Loosen the stylet for removal
b. Check for blood return in the flashback chamber
c. Stabilize the catheter and release the tourniquet
d. Advance the catheter until the hub rests at the insertion site
Observe for blood return through the flashback chamber of the catheter or the tubing of the winged cannula, indicating that the bevel of the needle has entered the vein. Lower the needle until almost flush with the skin. Advance the catheter another to inch into the vein, and then loosen the stylet site on the ONC. Only after the catheter is advanced and is in its final position is the catheter stabilized with one hand while the tourniquet is released. Only after the blood and the needle are observed to advance another to inch into the vein is the stylet loosened. At that point, continue to hold the skin taut, and advance the catheter into the vein until the hub rests at the venipuncture site.
What should the nurse do once she recognizes that the patient has phlebitis at his IV site?
a. Reduce the IV flow rate.
b. Elevate the affected extremity.
c. Place a moist warm compress over the site.
d. Adjust the additive in the current IV.
What should the nurse do upon noting bleeding around a dressing at an IV insertion site?
a. Discontinue the IV.
b. Assess the insertion site.
c. Leave the dressing intact, but reinforce it.
d. Elevate and apply warm compresses to the extremity.
When blood appears on the dressing, verify that the system is intact, and change the dressing. The IV should be discontinued in the event of infiltration or phlebitis. If bleeding occurs around the venipuncture site and the catheter is within the vein, gauze dressing may be applied over the site. Be aware that if gauze dressing is used, it must be removed to accurately assess the insertion site. Elevation is used in cases of infiltration to reduce edema. Warm compresses are used in cases of phlebitis.
Which patient would a nurse anticipate would be a candidate for a peripherally inserted central catheter (PICC)?
a. An older adult who is having cataracts removed
b. A perinatal patient who is having prolonged labor
c. A neonate requiring blood therapy
d. An adolescent who is having surgery for reduction of a fracture
When a child is critically ill or when long-term IV access is anticipated, a PICC catheter, a Broviac catheter, or an implanted port may be used to access a larger vein. PICCs can be used to infuse IV fluids, parenteral nutrition, blood and blood products, and medications such as antibiotics. Gerontological veins are very fragile, with less subcutaneous support tissue and with thinning of the skin. In older patients, use the smallest gauge possible. For example, a 22-gauge needle is adequate for fluid and medication therapy. PICC lines are not inserted routinely. PICCs are used when long-term IV is needed.
The nurse is caring for a patient receiving intravenous therapy. The nurse should report which of the following to the primary care provider?
a. Completion of each liter of fluid
b. Initiation of IV fluids
c. Small infiltration
If a patient suffers an extravasation, the primary care provider should be notified as soon as possible because complications of some vesicants can be reduced by injection of specific medications, whereas others require rapid medical intervention. It is not necessary to report when you routinely initiate or complete IV therapy. Primary care providers do not need to be notified of a small infiltrate, but it should be documented in the patient’s medical record, and your facility may require completion of an event reporting form.
The patient has an IV ordered to infuse at 1000 mL over 10 hours. The infusion set has a calibration of 15 gtt/mL. At which rate does the nurse regulate the infusion?
a. 20 gtt/min
b. 25 gtt/min
c. 30 gtt/min
d. 32 gtt/min
Select one of the following formulas to calculate drop rate based on drops per minute: mL/hr/60 min = mL/min followed by Drop factor mL/min = Drops/min, or mL/hr Drop factor/60 min = Drops/min.
The order is for the patient to receive 500 mL over 4 hours. The nurse has an electronic infusion device (EID) in place that provides for the regulation of hourly infusion. The IV tubing available is 10 gtt/mL. What is the setting for the infusion device?
a. 125 mL/hr
b. 500 mL/hr
c. 21 gtt/min
d. 32 gtt/min
For use of EID for infusion, turn on the power button, select the required drops per minute or volume per hour, close the door to the control chamber, and press the start button. In this case, 500 mL/4 hr = 125 mL/hr.
A pediatric patient has an IV with a microdrip. The order is for 40 mL/hr to infuse. At what rate does the nurse set the microdrip?
a. 10 gtt/min
b. 20 gtt/min
c. 40 gtt/min
d. 80 gtt/min
Select one of the following formulas to calculate drop rate based on drops per minute: mL/hr/60 min = mL/min followed by Drop factor mL/min = drops/min, or mL/hr Drop factor/60 min = drops/min. In this case, 40 mL/hr 60 gtt/mL = 240 gtt/hr 1 hr/60 min = 40 gtt/min. When microdrip is used, mL/hr always equals gtt/min.
While assessing the patient’s IV infusion, the nurse notes that it is infusing more slowly than it should be. What should the nurse do first?
a. Discontinue the IV.
b. Increase the rate of infusion.
c. Observe for fluid overload.
d. Check the position of the IV fluid and extremity.
The nurse caring for a patient receiving IV fluids knows that the current recommendation for changing the tubing on a continuously running IV is:
a. at least every 48 hours.
b. every 24 hours.
c. no more often than every 96 hours.
d. with each IV solution bag change.
Intravenous tubing administration sets remain sterile for 96 hours. Thus, the INS recommends changing tubing no more frequently than every 96 hours. When possible, schedule tubing changes when it is time to hang a new IV container.
The nurse is caring for a patient diagnosed with pneumonia who receives IV antibiotics every 8 hours. How often should the nurse change the primary intermittent IV sets?
a. No more often than every 72 hours
b. At least every 72 hours
c. With each IV bag change
d. Every 24 hours
You should change primary intermittent sets every 24 hours because the IV system becomes interrupted, which increases the risk for contamination.
What is an appropriate technique for the nurse to implement when changing the dressing at a peripheral IV site?
a. Wear sterile gloves to remove the old dressing.
b. Keep one finger over the IV catheter until the tape is replaced.
c. Cleanse with an antiseptic solution in a circular manner toward the site.
d. Tape the connection between the IV catheter port and the tubing.
Keep one finger over the catheter at all times until the tape or dressing secures placement. If the patient is restless or uncooperative, it is helpful to have another staff member assist with the procedure. Perform hand hygiene. Apply disposable gloves. Apply the final swab in a circular pattern, moving outward from the insertion site. Do not tape over the connection of the access tubing or port to the IV catheter.
What should the nurse do when discontinuing a peripheral IV?
a. Withdraw the catheter quickly.
b. Keep the hub perpendicular to the skin.
c. Apply pressure to the site for 1 minute.
d. Inspect the catheter for intactness after removal.
The patient is expected to require intravenous therapy for several years as treatment for a chronic disease process. Which of the following would be the best choice for venous access in this patient?
a. Peripherally inserted central catheter (PICC)
b. Nontunneled percutaneous central venous catheter
c. Subcutaneous implanted port
d. Peripheral IV
Implanted infusion ports are used for long-term and complex IV therapy. When not in use, no external catheter is present, and port manufacturers recommend that the port be heparinized every 4 weeks to maintain patency. No other care is required for an unused port. PICCs provide alternative IV access when the patient requires intermediate-length venous access (>7 days to several months). These catheters are used for shorter placements (e.g., 5 to 10 days). Use of peripheral IV therapy increases the risk for patients to develop infection, vein sclerosis, phlebitis, and infiltration.
The nurse is assisting the physician during the insertion of a central line into the subclavian vein. How should the nurse cleanse the area?
a. With chlorhexidine in a back and forth scrubbing motion
b. With chlorhexidine followed by alcohol in a back and forth scrubbing motion
c. With alcohol in a circular motion for 5 minutes
d. With antimicrobial solution that must be dabbed dry with a sterile towel
Antiseptics such as chlorhexidine remove resident and transient bacteria. Alcohol should not be applied after the application of iodophor solution. Chlorhexidine is scrubbed in a back and forth motion for 30 seconds. Allow the antimicrobial solution to air-dry completely. This ensures maximum antimicrobial effect.
The nurse is preparing to draw blood from a central venous access device for blood cultures. Which of the following steps is part of that process?
a. Apply sterile gloves.
b. Flush the port with 5 to 10 mL of 0.9% sodium chloride.
c. Slowly aspirate 5 mL of blood and discard the syringe.
d. Use the distal lumen to draw blood.
Use the distal (red or brown) lumen to draw blood if the device has more than one lumen. The distal (red or brown) lumen typically is the largest-gauge lumen. Apply clean gloves to prevent transfer of body fluids. Do not flush before drawing blood for blood cultures. If blood cultures have been ordered, do not discard any blood. Use the initial specimen for blood cultures.
What should the nurse do to decrease the potential for infection related to IV therapy?
a. Use the clean technique for dressing changes.
b. Change the IV tubing every 12 hours.
c. Palpate the insertion site daily through the intact dressing.
d. After cleansing the skin, dab it dry with a sterile gauze pad.
The nurse is caring for a patient with a continuous intravenous infusion of 0.9% normal saline with 40 mEq of potassium chloride added to each liter. During a routine hourly check of the infusion, the nurse discovers that 4 hours of fluid has infused in the past 1 hour. The nurse’s first action should be to:
a. notify the primary care provider.
b. assess the patient.
c. reduce the infusion rate.
d. notify the charge nurse.
If the intravenous fluid is infusing 4 times faster than ordered, the first intervention should be to reduce the rate. Notification of the primary care provider and the charge nurse would occur after the flow rate is reduced and an assessment of the patient is performed. Although assessing the patient is vitally important, you do not want to allow the fluid to continue infusing at a rapid rate while you are performing the assessment.
The nurse is caring for a patient who has experienced hypovolemia secondary to acute vomiting and diarrhea. The nurse anticipates what type of intravenous fluid to be ordered by the health care provider?
a. Hypotonic or isotonic solutions
b. Hypertonic or isotonic solutions
c. Hypertonic solutions only
d. Whole blood
Hypotonic solutions are administered for cellular dehydration, whereas isotonic solutions replace intravascular fluid, so both of these might be appropriate for this patient. Hypertonic solutions pull fluid from extravascular spaces and would not be appropriate for this patient. Whole blood is not indicated because there is no evidence of blood loss.
Which of the following patients would the nurse anticipate requiring the placement of a central venous catheter?
a. A patient in same-day surgery who might require blood transfusions
b. A patient in the intensive care unit requiring multiple simultaneous intravenous medications
c. A patient in the cardiac care unit diagnosed with possible myocardial infarction
d. A patient on the surgical unit recovering from hernia repair
The most likely candidate for a central venous catheter is the patient in intensive care requiring the administration of multiple medications. The central venous catheter will simplify the administration of multiple medications to this critically ill patient. Because same-day surgery patients are expected to go home at the end of the day, it would be unlikely this patient would need a central catheter. A patient diagnosed with myocardial infarction would be unlikely to need a central line unless his condition deteriorated. A patient post hernia repair would be unlikely to require a central venous line unless complications arose, which is not indicated in this scenario.
The nurse assigns nursing assistive personnel (NAP) to care for several patients with continuous IV infusions. Which of the following can NAP assist with?
a. Changing empty IV solution containers
b. Confirming the correct IV drip rate
c. Assessing the patient for response to IV therapy
d. Informing the nurse if they notice anything abnormal
The patient is on daily weights and is receiving intravenous therapy. The nurse notices that the patient has gained 2 kg since the previous morning. What else would the nurse expect to observe? (Select all that apply.)
a. Dry skin and mucous membranes
b. Distended neck veins
c. Tenting of the skin
d. Crackles or rhonchi in the lungs
ANS: B, D
What should the nurse do upon noting that the patient’s IV site is pale, cool, and edematous? (Select all that apply.)
a. Stop the infusion.
b. Elevate the extremity.
c. Start a new IV.
d. Flush the IV site.
ANS: A, B, C
Infiltration is indicated by swelling and possible pitting edema, pallor, coolness, pain at the insertion site, and a possible decrease in flow rate. The nurse should stop the infusion and should discontinue the IV, elevate the affected extremity, start a new IV if continued therapy is necessary, and document the degree of infiltration and nursing intervention. Flushing the IV site is not recommended.
The nurse is preparing to start an IV on a 92-year-old patient. The nurse realizes that she may need to take which of the following actions? (Select all that apply.)
a. Avoid using veins in the hand.
b. Avoid using veins in the dominant arm.
c. Use the largest-gauge catheter possible for maximum flow.
d. Avoid using a tourniquet.
ANS: A, B, D
In older patients, use the smallest gauge possible. For example, a 22-gauge needle is adequate for fluid and medication therapy; use a 24-gauge in frail, older adults. Smaller-gauge catheters are less traumatizing to the vein but still allow blood flow to provide increased hemodilution of IV fluids or medications. If possible, avoid the back of the older adult’s hand or the dominant arm for venipuncture because they interfere with the older adult’s independence. Minimize pressure from tourniquets, or avoid them if possible. Apply a blood pressure cuff in place of a tourniquet.