Question 1

The nurse is preparing heparin to use as a flush for a patient's IV infusion site.For which type of site is the nurse providing care?

Accepted Answer

A)   Peripheral access device
B)   Intermittent access device
C)   CVAD
D)   Intermittent piggyback device

Question 2

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?

Accepted Answer

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.

Question 3

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?

Accepted Answer

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."

Question 4

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?

Accepted Answer

A)   Excess fluid volume
B)   Decreased cardiac output
C)   Ineffective tissue perfusion: peripheral
D)   Imbalanced nutrition: greater than body requirements

Question 5

The nurse needs to dilate a patient's vein prior to inserting an IV catheter.Which technique should the nurse use to dilate the patient's vein?

Accepted Answer

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.

Question 6

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?

Accepted Answer

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. B

Question 7

Upon entering a patient's 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?

Accepted Answer

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. A

Question 8

As soon as the nurse begins to insert an IV catheter in the patient's antecubital space,a hematoma forms at the site.What should the nurse do first?

Accepted Answer

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.

Question 9

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?

Accepted Answer

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.

Question 10

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?

Accepted Answer

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.

Question 11

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 patient's IV access site?

Accepted Answer

A)   Infection
B)   Embolism
C)   Infiltration
D)   Venous spasm

Question 12

The nurse analyzes the fluid volume status of assigned patients.Which patients are most likely to need continuous IV therapy? (Select all that apply.)

Accepted Answer

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 Alzheimer's disease who refuses to eat or drink

Question 13

The nurse suspects a patient receiving IV therapy is experiencing fluid overload.Which assessment should the nurse perform first?

Accepted Answer

A)   Check the patient's weight.
B)   Assess lung sounds for crackles.
C)   Observe the patient's feet for edema.
D)   Inspect the insertion site for infiltration.

Question 14

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?

Accepted Answer

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.

Question 15

An IV insertion site begins to leak,and the tape over the site is wet.What should the nurse do first?

Accepted Answer

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.

Question 16

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.)

Accepted Answer

A)   Phlebitis
B)   Infiltration
C)   Septicemia
D)   Air embolism
E)   ExtravasationF)  Fluid overload

Question 17

A patient is prescribed IV fluid to replace electrolytes and expand plasma volume.Which type of fluid will the nurse provide to the patient?

Accepted Answer

A)   Isotonic solution
B)   Dextrose solution
C)   Hypotonic solution
D)   Hypertonic solution D

Question 18

The nurse is preparing to flush a patient's intermittent IV catheter.Why is the nurse flushing this catheter?

Accepted Answer

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

Question 19

The nurse is preparing to administer a bolus IV medication through a patient's saline lock.Which action should the nurse take immediately before providing the patient with this medication?

Accepted Answer

A)   Calculate the drip rate.
B)   Prepare the saline flush.
C)   Cleanse the hub for 15 seconds.
D)   Check the order for the medication.

Question 20

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?

Accepted Answer

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 doesn't get too high."
D)   "There is a lot of sugar in the solution, which can increase the risk for rebound hypoglycemia."

Exam 7: Nursing Care of Patients Receiving Intravenous Therapy

The nurse is preparing heparin to use as a flush for a patient's IV infusion site.For which type of site is the nurse providing care?

Correct Answer
verified

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?

Correct Answer
verified

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?

Correct Answer
verified

Correct Answer
verified

The nurse needs to dilate a patient's vein prior to inserting an IV catheter.Which technique should the nurse use to dilate the patient's vein?

Correct Answer
verified

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?

Correct Answer
verified
B

Upon entering a patient's 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?

Correct Answer
verified
A

As soon as the nurse begins to insert an IV catheter in the patient's antecubital space,a hematoma forms at the site.What should the nurse do first?

Correct Answer
verified

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?

Correct Answer
verified

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?

Correct Answer
verified

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 patient's IV access site?

Correct Answer
verified

The nurse analyzes the fluid volume status of assigned patients.Which patients are most likely to need continuous IV therapy? (Select all that apply.)

Correct Answer
verified

The nurse suspects a patient receiving IV therapy is experiencing fluid overload.Which assessment should the nurse perform first?

Correct Answer
verified

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?

Correct Answer
verified

An IV insertion site begins to leak,and the tape over the site is wet.What should the nurse do first?

Correct Answer
verified

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.)

Correct Answer
verified

A patient is prescribed IV fluid to replace electrolytes and expand plasma volume.Which type of fluid will the nurse provide to the patient?

Correct Answer
verified
D

The nurse is preparing to flush a patient's intermittent IV catheter.Why is the nurse flushing this catheter?

Correct Answer
verified

The nurse is preparing to administer a bolus IV medication through a patient's saline lock.Which action should the nurse take immediately before providing the patient with this medication?

Correct Answer
verified

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?

Correct Answer
verified

Exam 7: Nursing Care of Patients Receiving Intravenous Therapy

The nurse is preparing heparin to use as a flush for a patient's IV infusion site.For which type of site is the nurse providing care?

Correct AnswerverifiedShow Answer

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?

Correct AnswerverifiedShow Answer

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?

Correct AnswerverifiedShow Answer

Correct AnswerverifiedShow Answer

The nurse needs to dilate a patient's vein prior to inserting an IV catheter.Which technique should the nurse use to dilate the patient's vein?

Correct AnswerverifiedShow Answer

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?

Correct AnswerverifiedB

Upon entering a patient's 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?

Correct AnswerverifiedA

As soon as the nurse begins to insert an IV catheter in the patient's antecubital space,a hematoma forms at the site.What should the nurse do first?

Correct AnswerverifiedShow Answer

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?

Correct AnswerverifiedShow Answer

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?

Correct AnswerverifiedShow Answer

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 patient's IV access site?

Correct AnswerverifiedShow Answer

The nurse analyzes the fluid volume status of assigned patients.Which patients are most likely to need continuous IV therapy? (Select all that apply.)

Correct AnswerverifiedShow Answer

The nurse suspects a patient receiving IV therapy is experiencing fluid overload.Which assessment should the nurse perform first?

Correct AnswerverifiedShow Answer

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?

Correct AnswerverifiedShow Answer

An IV insertion site begins to leak,and the tape over the site is wet.What should the nurse do first?

Correct AnswerverifiedShow Answer

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.)

Correct AnswerverifiedShow Answer

A patient is prescribed IV fluid to replace electrolytes and expand plasma volume.Which type of fluid will the nurse provide to the patient?

Correct AnswerverifiedD

The nurse is preparing to flush a patient's intermittent IV catheter.Why is the nurse flushing this catheter?

Correct AnswerverifiedShow Answer

The nurse is preparing to administer a bolus IV medication through a patient's saline lock.Which action should the nurse take immediately before providing the patient with this medication?

Correct AnswerverifiedShow Answer

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?

Correct AnswerverifiedShow Answer

Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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B

Correct Answer
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A

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Correct Answer
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Correct Answer
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Correct Answer
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D

Correct Answer
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Correct Answer
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Correct Answer
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