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183 Cards in this Set
- Front
- Back
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True or false - the use of peripheral IV therapy increases the risk for patients to develop infection, vein sclerosis, phlebitis, and infiltration
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True
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What are the four types of central venous access devices?
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1. Nontunneled percutaneous central venous catheters
2. tunneled central venous catheters 3. peripherally inserted central catheter (PICC) 4. Implanted subcutaneous ports |
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Where is a PICC line inserted?
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Larger arm vein (end in superior vena cava)
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Where are CVADs inserted (the end of the line)?
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Into superior vena cava
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Nontunneled percutaneous central venous catheters are inserted directly into __ and are used for roughly __ day(s)
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Internal or external jugular, subclavian, or femoral veins
5 to 10 days |
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Primary complications associated with CVADs are usually related to __
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Infection caused by contamination of the catheter from the skin of the patient or from the health care worker
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Can the caring of a CVAD be delegated?
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No
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What are the most common indications for a central venous line?
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Chronic diseases;
Long term IV ABX; Chemotherapy; Frequent venipuncture; Difficult access; Frequent blood transfusions; Long term parental nutrition; Hemodynamic monitoring |
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What are the advantages and disadvantages of CVADs?
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Advantages:
Can be left in place longer than peripheral IV line (depends on type and manufacturer) Except for TLC Lower infection rate than peripheral line Can accommodate multiple/types of infusions Decreased venipuncture for client PICC lines may be inserted by a specially trained nurse; cost effective Implanted port is invisible Disadvantages: Risk for infection Occlusion Visible Catheters placed in the jugular or subclavian veins have limited access time Breakage/Leaking Phlebitis/ Vein sclerosis Migration Skin erosion Infiltration Extravasation |
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What are the flushing protocols for CVADs?
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10cc syringe with 10cc of NS;
Flush before and after infusion; 10cc syringe with 3cc flush of Heparin; (100units/ml) to lock line if not in use; Daily flushing times usually set by institution |
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What complications may occur with central venous access device insertion or during use?
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Blocked or difficult infusion of fluids (occlusion);
Pain and erythema at insertion site; Blood/fluid leakage; Infection; FVE, FVD; Electrolyte imbalances; Air / Pulmonary embolism; Malpositioning |
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How would a nurse recognize an occlusion from a CVAD insertion? What would be appropriate interventions?
What immediate interventions are necessary if these complications are suspected? |
No blood return;
Unable to flush; Neck or shoulder edema; Discomfort in arm, shoulder, neck Intervention: Assess tubing; Reposition client; C+DB; Raise arm; X-ray; Thrombolytics if ordered/clot aspiration |
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What would a nurse do if noticing bleeding or leaking from a CVAD insertion?
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Check for cause;
Check connections; Apply sterile gauze with pressure; Removal/reinsertion |
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How would a nurse detect infection from a CVAD line? What would be an appropriate intervention?
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Infection;
Redness, erythema, pain, tenderness; ↑ WBC count; Fever; + tip culture; Interventions: Blood cultures; Removal of line; ABX; New line |
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How would a nurse detect fluid volume excess from a CVAD? What would be appropriate interventions?
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FVE (fluid volume excess);
SOB (shortness of breath); Crackles; Edema; JVD (jugular venous distension); Interventions: Rate adjustment/ Stop infusion; Medications; CXR (chest x-ray) |
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How would a nurse detect fluid volume deficit from a CVAD? What would be appropriate interventions?
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FVD (fluid volume deficit):
Dry mouth; Dry skin; Change in VS; ↓ urinary output; Change in mentation; Interventions: Rate adjustment |
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How would a nurse detect electrolyte imbalance due to a CVAD? What would be an appropriate intervention?
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Lab values;
Physical s/s Interventions: Report to provider; Additions or deletions of electrolytes |
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How would a nurse detect an embolism from a CVAD? What would be an appropriate intervention?
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Dyspnea, cyanosis, ↓BP, ↑ pulse, loss of consciousness, pain (chest, shoulder, low back)
Interventions: Check connections/clamp tubing; Place client on left side / Trendelenburg; (traps air in right ventricle); VS; O2; Notify provider immediately; CXR |
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How would a nurse detect a pulmonary embolism from a CVAD? What would be an appropriate intervention?
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SOB, chest pain, ↓ O2 sat, restlessness, anxiety, ↑ rate, ↓ HR, cough, syncope
Interventions: High fowlers; Notify provider immediately; O2; VS; Morphine; CXR / VQ scan (ventilation/perfusion) |
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What are some signs of a malpositioned CVAD? What are some appropriate interventions?
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Irregular pulse;
↓ BP; Neck distention; Inadequate blood withdrawal Interventions Stop all fluids Notify provider Xray |
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What should the nurse document in the nurses’ notes about the exit site of a CVAD?
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Any:
Redness (erythema); Swelling (edema); Leakage; Warmth; Pain/tenderness; Occlusion; Dressing change |
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According to the article by Bartock (2010), what recommendations do the authors suggest as infection prevention measures for CVADs?
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Use of valved catheters;
Utilization of dedicated PICC insertion teams; Education of nursing staff |
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Which lab values are important in determining risk factors for nutritional deficits?
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Serum Albumin -- Normal 3.8-4.5
Measures protein depletion Lags behind changes for about 2 weeks Not a good indicator of acute changes. Pre-Albumin -- Normal 20mg/dL; Protein synthesizd by the liver; Shows up in 2 days BEST INDICATOR. Total protein -- Normal 6.4-8.3 g/dL; Combo of albumin and globulins; Globulins are building blocks of antibodies Transferrin Transports iron Electrolytes RBC’s |
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What foods are included in Clear and Full liquid diets?
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Clear
Tea Clear broth Ginger ale Frozen ices Jello Water Full Oatmeal Soup Ice Cream Eggs Pudding OJ |
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What foods are on a mechanical soft diet?
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Cream of wheat
Mashed potatoes Ground beef |
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What foods are on a puree diet?
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Pudding like texture
Pudding Yogurt |
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How will the nurse assist a patient who can not eat independently?
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Check ability to swallow
Dentures/glasses Activity level Elimination needs High-fowlers position Or on side with HOB elevated if not contraindicated Special devices Cut food into small pieces – position food in clock pattern Feed small amounts at a time and fluids Talk with patient After meal Patient hand hygiene Leave HOB ↑ for 30 minutes Clean up |
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What are the indicators that are most predictive for aspiration risk?
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Wet voice
Weak voluntary cough Coughing or choking on food Prolonged swallow Combo of any of the above |
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What are the two types of alternative feeding/nourishment interventions?
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Parenteral
TPN PPN Enteral NGT – short term PEG/PEJ – long term |
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Identify the clinical indications for Total Parenteral nutrition.
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Non-functional GI tract
Extended bowel rest Preoperative TPN Pre-op bowel rest Severe malnutrition GI tract non-usable for 4-5 days in catabolic clients |
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List the steps in administering TPN and lipids.
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Inspect insertion site/check patency
Obtain a blood glucose Monitor labs: renal function, electrolytes, glucose, liver functions VS, weight, auscultate lungs Verify MD order to solution Inspect solution for particulate matter or separation of fats Check ID Wash hands/apply gloves Use appropriate tubing and PRIME – no air bubbles Prime lipids and run as a tandem on a separate pump Place tubing in pump Connect tubing to patient Set to ordered rates |
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Identify 6 unexpected outcomes of a patient receiving TPN?
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Air embolism, localized infection, systemic infection, hyperglycemia, hypoglycemia, refeeding syndrome
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What should a nurse do if an air embolism results from TPN?
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Air embolism
Clamp catheter Position client on left side in trendelenburg Call MD O2 if needed Prevention: check that connections are secure; clamp when not in use; no stopcock valve |
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What should a nurse do if a localized infection develops from TPN?
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Localized Infection
Call MD Warm compress Oral ABX Daily site care Prevention: aseptic technique; dressing change every 7 days |
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What should a nurse do if a systemic infection develops from TPN?
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Systemic infection
ABX IV D/C catheter Prevention: full sterile barrier protection during insertion and dressing changes; use ABX impregnated catheters; no unnecessary tubing disconnections |
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What should a nurse do if hyperglycemia results from TPN?
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Hyperglycemia
Call MD May need to slow rate (MD order) Prevention: glucose monitoring; keep rate as ordered (do not speed up or slow down to catch up); aseptic technique |
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What should a nurse do if hypoglycemia results from TPN?
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Hypoglycemia
Call MD Give ½ cup of fruit juice if client not NPO Glucose monitoring after 15-30 minutes Prevention: decrease rate as ordered; continue blood glucose monitoring |
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What is refeeding syndrome and how can it be avoided?
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Refeeding syndrome: rapid drop in K+, Mg+, and phosphous in a severely malnourished client from TPN;
prevention: start TPN slowly |
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Differentiate between TPN and PPN.
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PPN:
<10% dextrose; temporary; contains amino acids and lipids; 600-700 osmolarity; less calories; short term TPN: >10% dextrose; long term; contains amino acids and lipids; 1800-2000 osmolarity; more calories; long term |
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What are the components and typical concentrations of TPN and lipids?
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Electrolytes: Na+, K+, Cl+, Mg+, Phos+, Ca+, Phosphate
Vitamins: K, MVI Proteins: Amino acids (5-15%) Glucose: Carbs (25% TPN); (10% PPN) Water Trace elements: zinc, selenium, chromium, manganese, iodine, copper, iron, and metallic elements Other (as ordered by MD): insulin, heparin, and ABX Lipids Fatty acids – linoleic acid Soybean or safflower oil base Should not exceed more than 60% of total calories Ideal is 30% or less 3 in 1 : amino acids, carbohydrates, and fats |
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What are the indications for enteral feedings?
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The patient can’t chew or swallow
But….GI tract CAN digest and absorb nutrients Length of time based on patient’s underlying problem |
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Differentiate between short-term and long-term feeding tubes.
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Short-term
Nasogastric tube (NGT) Oral gastric tube (OGT) Small-bore feeding tubes Used for a short period of time – not permanent. Long-term: Types Gastrostomy tube - PEG Jejunostomy tube - PEJ Surgical placement into stomach or jujunum Permanent |
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Discuss how to check for residual when administering a tube feeding.
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Apply gloves
Check tube placement first (Ph method) IN STOMACH – pH OF 1- 4; small intestine pH>6 Aspirate back into syringe and pull entire volume of gastric contents Return all contents if < 200ml If > 200ml contact MD Irrigate tube Begin feeding if < 200ml residual; otherwise need MD order |
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WHAT ARE THE RECOMMENDATIONS BY BOULLATA (2009)FOR ADMINISTERING DRUGS VIA A FEEDING TUBE?
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Administer each med separately
assure the med is being given in the correct portion of the GI tract dilute solid or liquid medication appropriately & use clean syringe avoid mixing medications intended through feeding tube if incompatible stop feeding before giving meds flush with 15ml water before and after each medication flush tube once more after all meds given don’t forget to restart feeding |
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What size syringe should be used for a CVAD blood draw? Why?
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ALWAYS USE A 10mL SYRINGE (OR LARGER)……SMALLER = TOO MUCH PSI PRESSURE THAT CAN RUPTURE PICC CATHETERS (simpler to just remember this and use for ALL CVAD’s)
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How much saline should be flushed before a blood draw (CVAD)? Why?
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Flush with 5-10mL saline BEFORE blood draw (except for blood cultures). This will assure catheter is patent first.
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After flushing with saline prior to a blood draw, what should be done with the saline in the catheter?
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Need to withdraw the saline that’s in the catheter OUT before drawing the blood sample (so, aspirate 5mL and DISCARD it in the Sharps Container.
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When feeding a patient in bed, what position should the bed be in before and after eating?
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Assure that the patient’s head of bed (HOB) is elevated 45
degrees during and AFTER feeding (for at least 30 minutes)” |
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Why are NGT known as "blind insertion" devices?
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You really don’t know where the tip is until you confirm it. If the tube is inserted for enteral feedings, the physician MUST order an x-ray to check placement AND you must get the results that it is indeed in the stomach BEFORE you start ANY enteral feedings.
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Can vaseline ever be used to insert an NGT?
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No, never -- only specific lubricant like surgilube.
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When inserting an NGT, what should you be aiming for?
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Nasopharynx
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What is the frequency of irrigation for a feeding tube?
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Usually every 4 to 12 hours (each hospital may vary)
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How often should an irrigation set be replaced for a feeding tube?
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The irrigation set should be replaced every 24 hours. If you’re flushing an NGT and the set does not have a date/time……discard and get a new one.
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While on TPN, the goal is for the patient to gain __ pounds per week.
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1 - 3 lbs
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True or false - TPN is ALWAYS administered via an infusion pump.
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True
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If a CVAD is being used for parenteral nutrition administration, can it also be used for blood draws and medication administration?
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No - when a CVAD is used for parenteral nutrition administration, it should be
“dedicated” solely for that purpose. It should not be used for blood drawing or administration of any IV fluid or medications. Why? Every time you interrupt a closed sterile system you risk contamination….and with this type of solution, with a high dextrose content, infection is a real and serious risk. |
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What labs should be checked prior to starting lipid infusions?
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it is important to check the patient’s triglyceride level BEFORE starting lipid infusions and then 6 hours AFTER to assure the patient is able to metabolize the lipid solution.
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What type of tubing is required for lipid infusions? Why?
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Because lipid solutions are often prepared in a glass bottle, “vented”
tubing is required. When administering solutions in a bag, the bag collapses as the fluid is infused. This does not hold true for any solution in a bottle. As a result, this vented tubing allows for inflow of air into the bottle which allows the solution to flow into the patient’s IV. CHANGE EVERY 24 hours |
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When performing an NGT insertion, how do you gauge the length of tube to be inserted?
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Measure the tubing from the tip of the nose to the earlobe to the xiphoid process (sternum base); mark off the length with tape
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A client who has a feeding tube most likely has a nursing diagnosis of:
a. Impaired gas exchange b. Impaired swallowing c. Constipation d. Delayed gastric emptying |
b. Impaired swallowing
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Which client is most likely to receive total parenteral nutrition (TPN)?
a. A client hospitalized with dehydration from acute gastroenteritis of two days' duration b. A client with severe malnutrition due to metastatic cancer who is in a hospice program c. A client NPO following surgery for repair of gunshot wounds to the gastrointestinal system d. A client NPO following partial removal of the left lung and insertion of a chest tube |
c. A client NPO following surgery for repair of gunshot wounds to the gastrointestinal system
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What are the current recommendations for reducing occupational exposure to blood-borne pathogens during IV fluid and medication administration?
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Needleless connectors for IV delivery; protected needle IV connectors; needles that retract into a syringe; protective encasements to receive IV stylet as it is withdrawn from the catheter
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What are some isotonic solutions?
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5% Dextrose; 0.9% Normal Saline; Lactated Ringers (has no calories – only electrolytes)
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What are some examples of hypotonic solutions? What are they used for?
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0.45% Normal saline; 0.33% Normal saline
Used for free water; replacing hypotonic fluid losses (dehydration); maintenance – no calories or replacement of daily losses of electrolytes |
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What are some examples of hypertonic solutions? What are they used for?
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D5%/10% - free water with no electrolytes; 3 – 5% Normal Saline – used to treat hyponatremia (but ca cause fluid overload and pulmonary edema); D5%/0.45% Normal Saline – 170 Calories; D5%/0.9% Normal Saline – 170 Calories;
Used to pull fluid INTO vascular space and thus rid the body of excess fluid (as in edema) |
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What is the difference between osmolality and osmolarity?
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Osmolality is the number of mOsm/kg of SOLVENT (concentration of particles dissolved in fluid, as in serum – 282-295mOsm/kg water); Osmolarity is the number of mOsm/liter of SOLUTION (concentration of a solution, as in plasma osmolarity of 270-300 mOsm/L)
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What types of IV access devices are typically used for short term use and what types are used for long term use?
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Short Term:
Peripheral – Peripheral Jelcos IV Catheters and Midline Catheters Central – Hemodialysis Catheters, Umbilitcal Catheters; Pulmonary Artery Catheters; Percutaneous (Triple Lumen) Catheters; Internal Jugular Catheters; External Jugular Catheters. Long Term: Peripheral: NONE Central: PICC; Portacaths (implanted port); Tunneled Catheters |
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What are the differences between peripheral venous and central venous catheters?
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Peripheral venous catheters: End of line is in peripheral vein; can be used for administering SOME meds; short term only; cannot be used for drawing blood (generally)
Central venous catheters: End of line is in Superior Vena Cava; can be used for administering ALL meds; can be used long term; can draw blood from them |
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What factors can alter an IV flow rate?
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Changes in patient position; occlusion of site; bending at catheter location; vasospasm of vein; position of arm (flexion); infiltration (fluid goes into tissue), phlebitis (inflammation of vessel), fluid overload, clotting
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What types and volumes of solutions are used to flush an IV site?
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Peripheral: 1 – 3 mL of NS or heparin (10 units/mL)
Central lines: 5 – 10 cc of NS flush with optional 3cc heparin lock flush (100 cc/mL) – recommended 10cc syringe (review institution’s policy!) |
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What size catheters are more appropriate for adults? For children?
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Adults: 18 – 22 gauge; children: 22 – 24 gauge
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What should a nurse do if she/he meets resistance when attempting to flush an IV site?
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Check the clamp; do not force the solution (vein might be blown); reposition the needle without pulling it out (peripheral); reposition clients (esp. central line); check for kinks in tubing
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According to the CDC, how often should IV administration sets be changed (both primary and secondary)?
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Textbook: 72 hours; CDC: 72 hours; INS (2007): 72 hours
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How often should IV tubing containing blood products, blood, or lipids be changed?
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Every 24 hours; bag must not hang longer than 4 hours (bacteria LOVE blood)
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Identify the 7 unexpected outcomes of IV therapy and nursing interventions to prevent and/or treat these complications.
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Fluid volume deficit; fluid volume excess; electrolyte imbalance; phlebitis; infiltration; extravasation; bleeding
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What are the signs and symptoms of fluid volume deficit due to IV therapy? Interventions?
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Signs and Symptoms: decreased urine output; dry mucous membranes; decreased capillary refill (more than 3 seconds); disparity in central and peripheral pulses; tachycardia, hypotension, shock
Interventions: Notify health care provider; adjustment of rate (possible); check electrolytes (labs) |
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What are the signs and symptoms of fluid volume excess due to IV therapy? Interventions?
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Signs and Symptoms: crackles; BP changes; JVD (jugular vein distention; shortness of breath; edema; intake greater than outtake
Interventions: STOP infusion; notify health care provider immediately |
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What are the signs and symptoms of electrolyte imbalance due to IV therapy? Interventions?
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Signs and symptoms: abnormal lab values; change in mentation; change in neuromuscular status; cardiac arrhythmias; VS changes
Interventions: notify health care provider; fluid type adjustment |
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What are the signs and symptoms of phlebitis due to IV therapy? Interventions?
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Signs and symptoms: swelling at site; redness at site; tenderness at site; may palpate a cord
Interventions: STOP infusion; remove IV catheter; warm compresses; treat IV site per facility’s policy; insert new IV away from site; document findings/interventions |
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What are the signs and symptoms of infiltration due to IV therapy? Interventions?
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Signs and symptoms: coolness; pallor; swelling; pain; decreased flow rate
Interventions: STOP infusion; remove IV catheter; assess and measure infiltration; CMS; estimate amount of infiltrate; elevate extremity; document; notify health care provider; provide extravasation care as ordered |
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What are signs and symptoms of extravasation due to IV therapy? Interventions?
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Signs and symptoms: Same as infiltration; burning/stinging; redness followed by blistering and tissue necrosis; different than infiltration as related to type of medication/solution that infiltrated; vescicant (medication fluid)
Interventions: SAME as infiltration; facility might require serial photographs; prepare for administration of local antidote (ex. Phentolamine for sympathomymetics) |
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What are the possible causes of bleeding due to IV therapy? What are the appropriate interventions?
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Can be caused by dislodgement of catheter from insertion site or disconnection of tubing
Interventions: Apply gauze dressing; assess site; assure use of luer lock connections or tape if not available; CHECK CONNECTIONS |
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How often should the nurse change the peripheral venous catheter dressing?
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Only when necessary (if wet, soiled, loose, every 48 hours if gauze dressing)
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What are the causes of speed shock in relation to IV therapy? What are the signs and symptoms?
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Causes: Sudden adverse reaction to IV medication administered too quickly; seen most often with medications given IV push or bolus; allergic type of reaction
Symptoms: flushed face; headache; chest tightness; irregular pulse; loss of consciousness; cardiac arrest |
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What type(s) of solution(s) may be piggybacked into packed red blood cells or whole blood?
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ONLY NORMAL SALINE
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What is the maximum amount of time a unit of blood can remain hanging?
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4 hours
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What are the 2011 patient safety goals related to blood transfusions?
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1. Match blood type to order (2 person verification process)
2. One person must be a qualified transfusionist 3. Second person must be qualified to assist in transfusion |
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A patient is having an acute hemolytic transfusion reaction. What signs and symptoms are most likely to be assessed?
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Fever; increased heart rate; sensation of heat or pain along vein; chills; lower back pain; chest tightness; dyspnea; HA; nausea; bronchospasm; anxiety
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What are the interventions, in order of priority, that a nurse must take if he suspects an acute transfusion reaction?
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#1 STOP INFUSION; KEEP IV site;
Remove blood and tubing; notify provider and blood bank; vital signs every 5 minutes, 10 minutes, 15 minutes for 1 – 3 hours; monitor fluid I’s and O’s; possibly a foley; obtain blood and urine samples; send unused blood back to lab; correct BP and coagulation; document |
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What are the most common types of transfusion reactions?
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Hemolytic reactions: Immune-mediated (ABO incompatibility); non-immune mediated (destruction of blood, physically or chemically)
Non-Hemolytic reactions: Immune-related (fever/chill reaction; allergic reaction; transfusion-related acute lung reaction); bacterial contamination; graft-vs-host disease); non-immune related (circulatory overload; bacterial contamination; hypothermia; hyperkalemia; hypocalcemia; hypoglycemia) |
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True or false – a fever/chill reaction to a transfusion is the body’s natural hemolytic response to RBC’s in the donated blood.
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False – It is the body’s natural non-hemolytic response to WBC’s in the donated blood
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When should red blood cells be administered and at what rate?
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Symptomatic anemia; as fast as the patient can tolerate (not longer than 4 hours)
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When should whole blood be administered and at what rate?
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Symptomatic anemia with large volume deficit; as fast as the patient can tolerate (no longer than 4 hours)
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When should fresh frozen plasma be administered and at what rate?
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Plasma protein deficiency or lack of specific coagulation factors that are unavailable; no longer than 4 hours
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When should plasma cryoprecipitate be administered and at what rate?
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TTP; no longer than four hours
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When should platelets be administered and at what rate?
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Bleeding due to thrombocytopenia or platelet function abnormality; less than four hours
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What part of the blood administration process can be delegated to an unlicensed assistive person?
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Picking up the blood product from the blood bank; vital signs
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In an emergency situation, what blood type can be administered without knowing the patient’s blood type?
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O Negative (but only for children and women of child bearing age); O Positive (but only for males and women beyond child bearing age)
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The LPN/LVN is assisting the RN to prepare for a blood transfusion. Which IV fluid will the LPN/LVN obtain to administer before and after the blood?
1. D5W 2. D5 in half normal saline 3. Half normal saline (0.45% NaCl) 4. Normal Saline (0.9% NaCl) |
Answer - Normal saline, or 0.9% sodium chloride, solution is used with transfusion therapy and is established in policies and procedures.
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When the nurse suspects a possible transfusion reaction, he or she will first:
1. Notify the physician 2. Monitor the client every 5 minutes or until you determine if a serious or mild reaction is occurring 3. Stop the transfusion. Disconnect the blood and blood tubing and discard them immediately. 4. Stop the transfusion. Change the IV tubing and start a saline infusion at a keep-open rate |
Answer - Treat all reactions seriously until proven otherwise. Upon suspicion of a transfusion reaction, stop the transfusion, change the IV tubing and start a saline solution at a keep-open rate. Do not discard the blood container or administration set. These will be returned to the blood bank. Notify the physician.
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A client has severe anemia. Which type of transfusion would you expect to be ordered for him?
1. Cryoprecipitate 2. Red Blood Cells 3. Albumin 4. Platelets |
Answer - Red blood cells are given to increase hemoglobin levels in severe anemia; platelets and cryoprecipitate are given for coagulation disorders, and albumin is given to increase plasma volume.
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A client with congestive heart failure is on continuous IV fluids. He complains of being uncomfortable and having difficulty breathing. To further assess this client the nurse would:
1. Check for mental status changes and a rapid, weak pulse. 2. Listen for crackles in the lungs and look for intake greater than output. 3. Get a tympanic temperature and check the white blood cell count. 4. Check the skin for a rash and listen for wheezes in the lungs. |
Answer - For circulatory overload, assess for neck vein engorgement, crackles in the lungs, and changes in intake and output. This complication may be caused by a too-rapid flow rate, an error in fluid requirements, or IV therapy in a client with renal or cardiac conditions.
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__ fluids have the same osmolarity as body fluids and are used most often to replace extracellular volume (eg. prolonged vomiting).
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Isotonic
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__ fluids effectively mimic the body's fluid loss in the absence of an electrolyte imbalance.
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Isotonic
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__ solutions are those that have an effective osmolarity LESS than that of body fluids.
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Hyptotonic
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__ solutions are those that have an effective osmolarity GREATER than that of body fluids and can be used in cases of dehydration.
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Hypertonic
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___ solutions pull fluid into the vascular space by osmosis, resulting in an increased vascular volume that will possibly result in pulmonary edema.
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Hypertonic
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Under no circumstances should a nurse give potassium chloride via ___
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IV Push
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True or false - fluid and electrolyte imbalances affect vital signs.
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True
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Dehydration sometimes produces __ (hypotension/hypertension).
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Hypotension
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True or false - fluid overload can result in hypotension and a weak pulse.
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False - fluid overload can result in hypertension and a bounding pulse.
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True or false - As part of IV administration, the saline lock should be flushed with 0.9% sodium chloride solution or after each administration of medication to maintain patency of the IV catheter (according to institution protocol).
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True
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Why should IV tubing be kept free of air and air bubbles?
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Air bubbles, esp. large ones, can result in and act as emboli.
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What are the best veins for IV placement in adults?
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Cephalic, basilic, and median cubital veins of the arm
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How often should a nurse monitor a patient receiving IV therapy?
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Every 1 to 2 hours to assure correct administration of fluid volume
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What additional sites can be used for IV therapy for pediatric clients (in addition to the sites used for adults)?
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Veins in the scalp or the foot in infants
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True or false - nurses should avoid using chlorhexidine as a prepping agen in infants less than 1000 g when administering IV therapy.
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True -- chlorhexidine is associated with dermititis in infants
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True or false - when administering IV therapy to geriatric clients, the same gauge needle is used as for adults.
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False - one should use the smallest gauge needle possible due to the fragility of gerontological veins, less subcutaneous tissue, and thin skin
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What is the minimal rate of IV infusion to keep a vein patent?
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10 to 15 ml/hr
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Why are infusion pumps almost always used with children?
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They infuse very small amounts and accurately provide the prescribed volume of IV solution
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How often should IV tubing be changed in the case of blood, blood products, and lipid emulsions?
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Every 24 hours due to risk of infection and bacterial growth.
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When selecting a site for IV therapy, the nurse chooses:
a. A site close to a valve in a vein. b. A site that is most proximal to the elbow. c. A site that supports IV therapy for 48 hours or less. d. A vein that is most distal, avoiding the fingers. |
Answer: A vein that is most distal, avoiding the fingers.
Duration of IV therapy: Select a vein that supports IV therapy for at least 72 hours. Begin therapy at the most distal area for long-term therapy. Avoid using the fingers. Choose a soft, straight vein for venipuncture. |
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As the nurse prepares the IV site, he or she will do which of the following? (Choose all that apply.)
a. Trim excess hair from the site with scissors. b. Cleanse area with alcohol followed by Betadine. d. Check to see if the client is allergic to iodine. e. Prep the skin with alcohol using a vigorous back and forth motion. f. Shave the area of excess hair. |
Correct Answers:
Cleanse area with alcohol followed by Betadine. Trim excess hair from the site with scissors. Check to see if the client is allergic to iodine. The nurse may need to remove excess hair. INS suggests the use of scissors for this. A razor can cause impairment of the skin integrity. Ensure that the client does not have an iodine allergy prior to prepping the skin. Prep with alcohol using a circular motion from inside out and allow to dry for one minute. Next apply Betadine, a germicidal solution. Once it has dried for 1 minute, it is effective for up to 6 hours. |
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A client states that she is extremely nervous because the last time she had an IV started, she had a bad reaction. To minimize such problems with this IV, the nurse:
a. Explains each step of the procedure in specific detail before beginning the venipuncture. b. Distracts the client with conversation, keeping the needle out of sight until the last minute. c. Reassures the client by telling her the number of IVs successfully started by the nurse. d. Discusses previous clients who have had severe reactions to IV starts. |
Answer: Distracts the client with conversation, keeping the needle out of sight until the last minute.
When the client is extremely nervous and has a needle phobia, a vasal-vagal response can ensue. Put the client at ease by engaging in conversation. Keep the needle out of sight until the last minute as this may decrease the severity of the response. |
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Some central venous access devices (CVAD) have more than one lumen. These multi lumen catheters:
a. Have an increased risk of infiltration. b. Only work a short while because the small bore clots off. c. Are beneficial to patient care but are prohibitively expensive. d. Allow different medications or solutions to be administered simultaneously. |
Answer D. A multilumen catheter contains separate ports and means to administer agents. An agent infusing in one port cannot mix with an agent infusing into another port. Thus, agents that would be incompatible if given together can be given in separate ports simultaneously.
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Some institutions will not infuse a fat emulsion, such as Intralipid, into central venous access devices (CVAD) because:
a. Lipid residue may accumulate in the CVAD and occlude the catheter. b. If the catheter clogs, there is no treatment other than removal and replacement. c. Lipids are necessary only in the most extreme cases to prevent essential fatty acid (EFA) deficiency. d. Fat emulsions are very caustic. |
Answer A. Occlusion occurs with slow infusion rates and concurrent administration of some medications. Lipid occlusions may be treated with 70 percent ethanol or with 0.1 mmol/mL NaOH. Lipids provide essential fatty acids. It is recommended that approximately 4 percent of daily calories be EFAs. A deficiency can quickly develop. Daily essential fatty acids are necessary for constant prostaglandin production. Lipids are almost isotonic with blood.
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A male patient is to receive a percutaneously inserted central catheter (PICC). He asks the nurse whether the insertion will hurt. How will the nurse reply?
a. “You will have general anesthesia so you won’t feel anything.” b. “It will be inserted rapidly, and any discomfort is fleeting.” c. “The insertion site will be anesthetized. Threading the catheter through the vein is not painful.” d. “You will receive sedation prior to the procedure.” |
Answer C. Pain related to PICC insertion occurs with puncture of the skin. When inserting PICC lines, the insertion site is anesthetized so no pain is felt. The patient will not receive general anesthesia or sedation. Statement 2 is false. Unnecessary pain should be prevented.
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The LPN/LVN is starting an IV with orders to hang D5W with 20 mEq of potassium for administering intermittent antibiotics. The nurse will select which vein?
a. A small vein on the underside of the wrist. b. A small vein in the back of the hand. c. A large vein in the forearm. d. A large vein in the antecubital space. |
Correct Answer:
c. A large vein in the forearm. Avoid using the antecubital site unless warranted by an emergency. Hypertonic solutions, potassium chloride, and antibiotics are irritating to the vein walls. Select a large vein to accommodate these solutions. |
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What are blood volume expanders?
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Blood volume expanders are used to increase the volume of blood following a severe loss of blood (e.g., due
to hemorrhage) or plasma (e.g., due to severe burns when large amounts of plasma shift from the bloodstream to the burn site). Common blood volume expanders are dextran, plasma, and human serum albumin. |
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When administering a piggyback setup, which solution container should be lower?
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It is important for the primary container to be hung lower than the secondary container. By doing so, the center of gravity is lowered in the primary container and the secondary solution is allowed to flow. When the secondary container
is empty, the primary solution will resume administration. |
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What is a lumen?
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The "lumen" is the part of the IV in which a drug can be administered. There are devices such as a "triple lumen" catheter. There is one "lumen" which goes into the patient but the device itself has three ports where different drugs can be administered at the same time.
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There are two general types of CVADs. ___ have one end positioned outside the body, while ___ are surgically placed under the skin and require a special needle for access.
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Catheters; ports
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With both central venous catheters and ports, the opposite end of the tubing is positioned within ___
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The Superior Vena Cava
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What is the most common reason a CVAD may become occluded?
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Blood clot
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A nurse suspects that an IV has infiltrated. What steps should he take (select all that apply).
1. STOP infusion 2. Call the doctor 3. Remove IV catheter 4. Elevate the extremity |
All choices are correct
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True or false - D5W is classified as an Isotonic solution, but works as a hypotonic solution; the glucose is immediately used up by the cells and all that is left is extra water - thus water will move into the cells causing edema (if too much)
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True
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Why would you give a patient a hypotonic solution?
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Patient is dehydrated - gives cells more water
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What is the concentration of 0.9% sodium chloride (isotonic, hypertonic, hypotonic)?
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Isotonic
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What is the concentration of 3 - 5% sodium chloride (isotonic, hypertonic, hypotonic)?
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Hypertonic
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What is the concentration of 0.45% sodium chloride (isotonic, hypertonic, hypotonic)?
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Hypotonic
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A patient had his IV catheter inserted 48 hours ago to receive antibiotic therapy. During assessment of his IV site the nurse observes redness and tenderness upon palpation. The nurse documents that the IV was discontinued and restarted because of what complication of IV therapy?
1. Clotting of IV catheter 2. Infiltration 3. Phlebitis 4. Puncturing of the opposite side of the vein |
3. Phlebitis
Coolness and swelling would be seen with infiltration; there is no data to support the other options |
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A patient just had a PICC placed in his right antecubital site. When reading the x-ray report verifying correct placement of the catheter, the nurse knows the tip of the catheter is located correctly if it is in which vessel?
1. The inferior vena cava 2. The basilic vein 3. The cephalic vein 4. The superior vena cava |
4. The superior vena cava
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An obese patient who had a right masectomy several years ago has better veins in her right hand but is left handed. Where should the nurse place the IV catheter?
1. In her right hand 2. In her left lower arm 3. Wherever the patient wants 4. In her right antecubital site |
2. In the left lower arm
Although it is desirable to place in IV infusion in the patient's nondominant hand, this patient has a medical condition that dictates that the IV catheter be placed in her dominant hand or arm. |
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The physician discontinued a patient's anticoagulant therapy. What nursing intervention is most appropriate after the nurse removes the IV catheter from his hand?
1. Apply pressure to the IV site for 5 minutes 2. Convert the catheter to an intermittent heparin lock for 24 hours 3. Encourage the patient to keep his hand elevated for 10 minutes 4. Use a warm compress at the site for several minutes |
1. Apply pressure for 5 minutes
The patient is susceptible to bleeding, so pressure should be applied whenver a device is removed from his body while he still has prolonged bleed times. You or the patient can apply pressure for the required time. |
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A nurse is preparing a blood transfusion infusion set. Which solution should be used to prime the tubing?
1. 0.45% sodium chloride (1/2 NS) 2. Dextrose 5% in 0.45% NS 3. 0.9% sodium chloride (NS) 4. Dextrose 5% in 0.9% NS |
3. Normal saline
Normal saline is the only IV solution that can be used with blood because of its isotonic quality. Dextrose solutions cause hemolysis of the RBCs. |
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A patient with A - blood type needs a blood transfusion. Which blood types are appropriate for him to receive?
1. A+ or A- 2. A- or O+ 3. A- or O- 4. A+ or AB- |
3. Only negative blood types can be given to a patient with a negative blood type.
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A patient is to receive blood that has been stored for quite some time. What recent lab value should the nurse check before administering the unit?
1. Sodium 2. Hematocrit 3. Hemoglobin 4. Potassium |
4. When blood is stored, there is a continued destruction of blood cells, which release K into the plasma; if the blood is transfused rapidly, there may be transient hyperkalemia before the K is reabsorbed.
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A patient is to receive a blood transfusion. Which nursing action has the greatest impact on reducing a potential transfusion reaction?
1. Administering an antihistamine 15 minutes prior to transfusion 2. Comparing the patient's ID bracelet with the blood bag label number 3. Ensuring that the patient knows what his or her blood type is 4. Obtaining the patient's previous transfusion history |
2. Comparing the patient's ID bracelet with the blood bag label number is the most important step to take.
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A patient receiving a blood transfuion begins having signs and symptoms of a transfusion reaction. Other than stopping the transfusion and assessing vital signs, what else should the nurse do
1. Hang a new infusion setup with D5W to maintain an access for meds 2. Finish infusing the blood remaining in the tubing, then flush the tubing with normal saline hanging on the Y-tubing 3. Keep the existing tubing patent with a dextrose solution in case diphenhydramine is needed 4. Hang a new infusion setup with NS to maintain an IV access |
4. It is essential to maintain an IV access, but you do not want the patient to receive any more of the current blood. Another blood administration set should be primed with a new bag of normal saline in case more blood needs to be given. Keep the old blood bag and saline as well as the administration set and send them to the appropriate department for analysis.
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A patient is receiving a 3:1 parenteral nutrition infusion. How often should the IV infusion tubing be changed?
1. Once a week 2. Every 24 hours 3. Every 72 hours 4. After each solution is administered? |
2. Every 24 hours or upon suspected contamination (whichever comes first)
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A patient has a small-bore nasal feeding tube that was just inserted. What is the most important fact that should be documented before the installation of any type of fluids?
1. Radiographic confirmation of nonrespiratory placement 2. Confirmation that the tube is in the stomach 3. Confirmation that the tube is in the intestine 4. The type and location of the feeding tube placement |
1. Radiographic confirmation of nonrespiratory placement
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What is the MOST important intervention the nurse can perform to prevent nosocomial infections associated with enteral nutrition?
1. Inserting the nasogastric tubes using sterile technique 2. Performing frequent hand hygiene 3. Wearing clean gloves when handling the feeding system 4. Changing the feeding bags and liquid on time |
2. Performing frequent hand hygiene has been found to be the most effective method of controlling nosocomial infections, regardless of the procedures.
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__ syringes require special needles, which are twisted on the tip and lock themselves in place, preventing the unintentional removal of the needle from the syringe.
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Luer-Lock
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After feeding tube placement has been confirmed, how often should a nurse reconfirm placement?
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Every 4 to 6 hours or as needed
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What does aspiration of red or brown fluid from a feeding tube mean?
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New or old blood from the GI tract
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How long can a PICC line remain in place?
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1 year
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How long can an implanted port remain in place?
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For life of need or until port head does not hold needle
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How long can a triple-lumen subclavian cath remain in place?
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For duration of acute care
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If there is a need for short-term nutrition and a patient's GI tract cannot digest food, what feeding type (TPN or PPN) is indicated?
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PPN
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How often does tubing for central parenteral nutrition need to be changed?
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Every 72 hours (though in some places, every 24 hours for new bag)
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How often does tubing for peripheral parenteral nutrition need to be replaced?
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Must be replaced every 24 hours
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How must a bag of lipids be administered in tandem with TPN/PPN?
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Piggyback at Y site closest to patient
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Can lipids be administered peripherally?
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Yes but with large gauge needle (18 or greater)
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How much NS is used when irrigating a feeding tube line?
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30 mL (record on Is and Os)
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How often is the injection cap for a CVAD changed?
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Whenever the dressing is changed, the cap is also changed
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True or false - a nurse must wear a mask when changing the dressing of a CVAD.
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True
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What is the solution of choice when cleansing a CVAD site?
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Chlorhexidine
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What does KVO mean?
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Keep vein open (Used for IV infusions)
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True or false - a marker or sharpie may be used to note day, time and initials on an IV bag.
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False - ink may absorb into bag.
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What is an IV piggyback? How is it often administered?
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An intravenous (IV) piggyback is a way to administer medication through an intravenous tube that is inserted into a patient's vein. This can be an antibiotic or another type of medication that needs to be diluted and administered slowly. The medication in an IV piggyback is mixed in a small amount of compatible fluid, such as normal saline or dextrose with saline.
The IV piggyback is aptly named because the medication is given on top of the main intravenous solution. This allows for the intermittent infusion of medications at specific times. The piggyback infusion usually is hung higher than the main IV solution and is connected to a port in the main tubing. Hanging the IV piggyback higher than the main solution causes it to infuse faster than the main solution. A pump may also be used instead of gravity. |
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What is an IV push?
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The intravenous or IV push or bolus is a means of delivering additional medication through an intravenous line, administered all at once, over a period of a minute or two. This contrasts with IV drip techniques where medicine is slowly delivered from an IV bag. An IV push has the advantage of being able to give extra medicine, as needed, without having to inject the patient elsewhere, and it can rapidly get this medicine into the body since it’s injected directly into the bloodstream. This technique also comes with noted cautions, since not all medicines can be delivered this way and some may cause extreme irritation or toxically high blood levels of a medicine, if they are given too quickly.
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True or false - meds can be added to an existing IV container for administration.
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False - Always add meds to a new container, not to an already hung IV container
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A piggyback container usually has how many mLs and is connected to what y-port?
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25-150mL; upper
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A tandem container usually has how many mLs and is connected to what y-port?
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25-250mL; lower
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What is a mini-infusion pump?
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Battery operated pump that delivers very small amounts (5-60mL) within controlled infusion times using standard syringes.
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What should the nurse do if meds administered via IV push begin to cloud the IV fluid?
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If IV fluid becomes cloudy, STOP. It means the IV med is incompatible with the fluid.
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This type of cath is surgically inserted through a tunnel in the sub q tissue, usually between clavicle and nipple, into the internal jugular or subclavian vein, tip resting in superior vena cava; it can remain in place for months to years.
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Tunneled catheter
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What is the advantage of a tunneled catheter?
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Tunneling decreases the risk for phlebitis and infection since it doesn’t go directly in the vein but the tissue for awhile first.
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How often does the dressing of a CVAD need to be changed?
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Gauze dressing needs to be changed every 48 hours, transparent dressings need to be cared for every 7 days and as needed.
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During a blood transfusion, the nurse should stay with the patient for the first ___ (time), and flow rate during this time should be ___.
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Stay with the patient for the first 15 minutes, and flow rate during this time should be 2mL/minute or 20gtt/min (using MACROdrip rate of 10gtt/mL)
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True or false - patients with AB blood type can give to and receive from all others.
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False -- they can receive from all others; O can give to all but can only receive O.
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A patient requiring a CVAD with separate ports for chemotherapy administration, blood sampling and pain medication will probably receive what type of CVAD?
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Triple lumen catheter - one lumen for each.
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How should a CVAD site be cleaned using an antiseptic swab? (Describe technique)
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Use antiseptic swab – go in a horizontal plane with the first swab, vertical plane with the second swab, and circular motion with the third swab.
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