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70 Cards in this Set

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Why is it important for the nurse check the expiration date on the bag and assess for cloudiness or leakage?
to ensure the solution is sterile
What is it important to unroll tubing and close roller clamp with opening a new infusion set?
Prevents fluid from leaking after IV bag is spiked
Why is it important to spike bag with tip of new tubing and compress drip chamber to fill halfway?
This promotes rapid flow of solution through new tubing without air bubbles.
What is it important when opening roller clamp to remove protective cap from the end of the tubing, and slowly flush solution completely through tubing?
This removes air from tubing. Prevents entry of air into the venous system, a cause of air embolus. If luid enters tubing too rapidly air bubbles occur.
Why is it important to close roller clamp and replace cap protector?
This prevents fluid from leaking and maintains sterility of tubing.
When removing old tubing and replacing with new tubing, why is it important to place sterile 2x2 gauze under IV catheter or heparin lock?
Absorbs fluids that may drip during the procedure, preventing contamination of surrounding areas.
When removing old tubing and replacing with new tubing, why is it important to stabilize the hub of catheter or needle and gently pull out old tubing?
Prevents accidental dislodging of catheter of needle.
When removing old tubing and replacing with new tubing, why is it important to quickly insert new tubing into hub of catheter or needle?
Prevents backflow of blood or the entrance of air into vein.
When removing old tubing and replacing with new tubing, why is it important to open roller clamp to establish flow of IV solution?
Prevents catheter occlusion and maintains IV flow at prescribed rate.
When assessing and maintaining an IV insertion site, why is it important to review client's history for medical conditions or allergies?
Decreases risk of fluid overload and allergic reactions.
When assessing and maintaining an IV insertion site, why is it important to
review client's IV site record and intake and output record?
Assesses for potential problems with fragile IV sites and fluid balance.
When assessing and maintaining an IV insertion site, why is it important to
obtain client's vital signs?
Assesses for changes in cardiovascular system.
When assessing and maintaining an IV insertion site, why is it important to
check IV fluid for correct fluid, additives, rate, and volume at the beginning of shift?
Ensures client is receiving correct therapy.
When assessing and maintaining an IV insertion site, why is it important to
check IV tubing for tight connections every 4 hours?
Ensures that no fluid leaks from tubing and connections.
When assessing and maintaining an IV insertion site, why is it important to
check gauze IV dressing hourly to be sure it is dry and intact?
Ensures there is no sign of infiltration or infection at IV insertion site.
When assessing and maintaining an IV insertion site, why is it important to
remove the dressing and observe site for redness, swelling, or drainage if the gauze is not dry and intact?
Ensures there is no sign of inflammation or infection at IV site.
When assessing and maintaining an IV insertion site, why is it important to
observe vein track for redness, swelling, warmth, or pain hourly?
These are early signs of phlebitis or infiltration.
When changing the IV solution, why is it important to prepare new bag with additives as ordered by health care provider?
Laboratory tests may reveal a need for potassium, insulin, or magnesium.
When changing the IV solution, why is it important to plan for new bag to be hung at least 1 hour before it is needed?
Reduces clot formation in vein caused by empty IV bag.
When changing the IV solution, why is it important to change solution when an hour's infusion of solution remains in the IV bag?
Prevents air from entering tubing and vein from clotting from lack of flow of fluid.
When changing the IV solution, why is it important to be sure drip chamber is at least half full?
Prevents entry of air into IV tubing while bag is being changed.
When changing the IV solution, why is it important to move roller clamp to stop flow of fluid;
remove old IV bag from IV pole and hang new bag;
spike new bag with tubing;
re-establish prescribed flow rate
Prevents fluid in drip chamber from emptying while changing solutions;
prepares equipment;
maintains sterility of solution; prevents clotting of vein
When changing the IV solution, why is it important to check air in tubing?
reduces risk of air embolus
How often should IV tubing be changed?
every 48 hours and when bag is changed to decrease risk of infection
True of false? If blood products infused, change to avoid occlusion with viscous solutions?
True
What is secondary tubing used for?
to add or "piggyback" another solution into primary tubing
What are the standard gtts per cc for macrodrops?
10, 15, 20
What is the standard gtts per cc for microdrops?
60
Possible nursing diagnosis for intravenous applications?
Impaired skin integrity
Risk for infection
Deficient knowledge,
regarding IV infusion
When should the nurse prepare for the next IV bag?
when 50 ml left and at least 1 hour before needed
What is the cost of dehydration?
65 year old and older and accounts for nearly 2 million hospital days per year in U.S. with estimated cost of 1.2 billion dollars
Which dehydration is most common?
isotonic dehydration
What are 3 reasons dehydration may occur related to periop care?
patient NPO
anesthesia slows metabolic
processes
wound drainage
Hypertonic dehydration happens because?
hyperventilation
renal failure
systemic infection
What are 2 reasons healthy adults migh experience mild dehydration?
overexertion during exercise
too much salt intake
Nursing interventions for fluid monitoring for client with diagnosis of deficient fluid volume?
monitor serum and urine
electrolyte values
monitor b.p., heart rate,
and respiratory status
monitor orthostatic blood
pressure
Nursing interventions for fluid management for client with diagnosis of deficient fluid volume?
Promote oral intake
Distribute the fluid intake
over 24 hours
Encourage significant other
to assist client with
feedings
Nursing interventions for oral health restoration for client with diagnosis of deficient fluid volume?
*Encourage frequent rinsing of mouth with any of the following, sodium bicarbonate solution, warm saline, or hydrogen peroxide solution

*Monitor lips, tongue, mucosa membranes, and gums for moisture, color, texture, presence of debris
What are common causes for isotonic overhydration (hypervolemia)?
poorly controlled IV therapy
renal failure
long-term corticosteroid
therapy
What are common causes for hypotonic overhydration?
early renal failure
psychogenic polydipsia
CHF
irrigation of wounds and
body cavities with
hypotonic fluids
syndrome of inappropriate
antidiuretic hormone
poorly controlled IV therapy
replacement of isotonic fluid
loss with hypotonic fluids
What are common causes for hypertonic overhydration?
excessive sodium ingestion
rapid infusion of hypertonic
saline
excessive sodium bicarbonate
therapy
Sudden weight gain indicates fluid retention. Each pound of weight gained after the first half pound is equal to
___________ml of retained water?
500
Does restricting fluids help
incontinence?
no
Should you give oral fluids to an unconscious patient?
no, because they may aspirate; use NG tube or catheterization
Minimum fluid intake for most patients who do not have other conditions that require fluid restrictions is _____liters/day?
3
IV solution should be changed?
every 24 hours
True or false? The nurse can decide what kind of IV solution to give patient after first bag?
False
The reason to prime IV tubing
with IV solution is to?
prevent air embolus
Sterile technique must be used when changing IV bag?
True or false
true
For most adults, the first option for IV placement is in?
hand or large veins of forearm, preferably in nondominant hand
Appropriate veins for IV insertion include?
basilic
cephalic
median
metacarpal
*use most distal portion of
vein first
When inserting IV, areas to avoid on the arms are?
arms that have had previous
mastectomy
edema
superior vena cava
infections
previous phlebitis
invading neoplasms
hematomas
sites distal to recent
venipunctures
areas of flexion and bony
prominence, such as wrist
and antecubital fossa
When assessing and maintaining an IV insertion site, assess for DEHYDRATION by observing?
behavior changes
confusion
decreased urine output
dry skin
flattened neck veins
inelastic skin turgor
mucous membranes
sunken eyes
vital signs change

*allows intervention to increase fluids and reduce dehydration
When assessing and maintaining an IV insertion site, assess for FLUID OVERLOAD by observing?
auscultation of crackles or
rhonchi in lungs
changes in vital signs
distended neck veins
level of consciousness
periorbital edema

*allows intervention to
decrease fluids
Who might develop complications from IV therapy?
vey young
very old
heart failure
renal failure

*allows for intervention of modifying procedure
Signs of complications at an IV site include?
infection
infiltration
bleeding
drainage
pallor
redness
swelling
warmth
phlebitis
How does the nurse observe the IV site for patency?
by briefly compressing the IV cannulated vein above the site; note slowing or momentary cessation of IV rate with a positive blood return

*poor patency may indicate need for changes
Possible nursing diagnosis for assessing and maintaining IV insertion sites include?
Impaired tissue integrity. Risk for inflammation caused
by indwelling peripheral
IV site
Risk for impaired skin
integrity.
Risk for infection, caused by
indwelling peripheral IV
site
Excess fluid volume
Deficient fluid volume
When assessing and maintaining an IV insertion site for a geriatric client,
remember that?
very fragile veins
look closely for signs of
infiltration
veins may "blow" more easily
don't use too much tape and
make it unabrasive
remove tape carefully
True or false? A peripheral IV insertion site is not frequently chosen for long-term IV therapy?
True
To verify patency of peripheral IV?
ASPIRATE (not irrigate) the IV
Which 4 factors affect the flow rate of a gravity-fed
IV?
Loose connection
Infiltration
Phlebitis
Height of the IV container
If a large soft vein in the forearm is not available, what would be your next best choice for an IV?
large soft veins in hand
Which of the following will promote venous dilatation?
Lowering arm below level of right atrium
Applying heat
Having client pump fist
When phlebitis or thrombophlebitis occurs, the first action is?
Relocate the IV
Who might receive a peripheral IV?
acutely ill
NPO after surgery
severe burns
someone receiving medication
through the IV every 4,6,
or 8 hours
Documentation after changing an IV solution should include?
*Flow Sheet
Date and time new IV
solution was started
*Initials of nurse changing
solution
*Intake and Output Record
*Amount of fluid infused
from old solution
*Amount of new solution hung
*Nurses' Notes
Any unusual findings or
client teaching
A standard IV infusion set consists of? (4)
*pre-filled, sterile
container (glass bottle,
plastic bottle or plastic
bag) of fluids with an
attached drip chamber which
allows the fluid to flow
one drop at a time, making
it easy to see the flow
rate (and also reducing air
bubbles);
*a long sterile tube with a
clamp to regulate or stop
the flow;
*a connector to attach to
the access device;
*and connectors to
allow "piggybacking" of
another infusion set onto
the same line, e.g., adding
a dose of antibiotics to a
continuous fluid drip.
Dehydration results in?
fluid volume deficit
Hypertonic, hypotonic, or isotonic is the most common IV given?
hypertonic..then isotonic...then hypotonic