ATI CH 4

Question 1

Large volume IV infusions are administered for how long?

Answer 1

On a continuous basis

Question 2

How may a IV medication be mixed?

Answer 2

It may be mixed in a large volume of fluid & given as a continuous IV infusion OR mixed In a Small amount of solution and given intermittently.

Question 3

What is a fluid bolus?

Answer 3

A large amt of IV fluid given in a short period of time, usually in less than one hr. It is given to rapidly replace fluid loss
That could be caused by dehydration, shock, hemorrhage
, burns or trauma.

Question 4

What are the appropriate size gauges for IV’s?

Answer 4

16 guage for trauma clients
18 guage for surgical clients, rapid blood administration
22-24 guage for all other adult clients.

Question 5

How do you select a vein for IV solutions?

Answer 5

Choose distal veins on non dominant hand
A site that is not painful or bruised
A vein that is resilient, with a soft, bouncy feeling.

Question 6

What are signs of infiltration?

Answer 6

Pallor, local swelling, decreased skin temp around the site, damp dressing, slowed infusion.

Question 7

What is the treatment of a IV that has been infiltrated?

Answer 7

Stop infusion & remove catheter
Elevate extremity
Encourage active range of motion
Apply cold or warm compress based on the type of solution that infiltrated the tissue.
Check w/ provider to see if IV still needed.

Question 8

What are the complications of a extravasated IV?

Answer 8

Pain, burning, redness, swelling

Question 9

What is the treatment of a extravasated IV?

Answer 9

Stop infusion, notify provider

Follow facility protocol, which may include infusing an antidote through the catheter before removal.

Question 10

What is a nursing intervention of a hematoma (ecchymosis) at IV site?

Answer 10

Do not apply alcohol
Apply pressure after catheter removal
Use warm compress and elevation when bleeding stops

Question 11

What are some preventions of a hematoma(ecchymosis) at the IV site?

Answer 11

Minimize tourniquet time
Remove tourniquet before starting IV infusion
Maintain pressure after catheter removal

Question 12

What would you do if you found a catheter embolus?

missing catheter tip when discontinued, severe pain at site with migration, or no symptoms of migration

Answer 12

Place the tourniquet high on the extremity to limit venous flow
Prepare for removal via X-ray or surgery
Save the catheter after removal to determine the cause

Question 13

What are preventions of a catheter embolus?

Answer 13

Do not reinsert the stylet into the catheter
Check to be sure the IV catheter
Is intact at the time of IV removal.

Question 14

What are signs of fluid overload via IV?

Answer 14

Distended neck veins, increased BP, tachycardia, SOB, crackles in the lungs
Edema

Question 15

What are nursing interventions of fluid overload?

Answer 15

Slow the IV rate to keep the vein open in accordance to facility policy.
Raise the head of bed
Assess vital signs
Adjust rate as prescribed
Anticipate administration of diuretics

Question 16

What are preventions for fluid overload?

Answer 16

Use an infusion pump

Monitor I&O

Question 17

What are signs & symptoms of cellulitis in IV therapy?

Answer 17

Pain, warmth, edema, induration, red streaking, fever, chills, and malaise.

Question 18

What is a nursing intervention of cellulitis?

Answer 18

Promptly discontinue the infusion n remove catheter
Elevate extremity
Apply warm compress 3-4x per day
Culture the site and cannula if drainage is present
Administer…antibiotics, analgesics, antipyretics

Question 19

What are some prevention strategies for cellulitis?

Answer 19

Rotate site at least every 72 hours
avoid the lower extremities
Use hand hygiene
Use surgical aseptic technique

Question 20

What are signs and symptoms of phlebitis/ thrombophlebitis?

Answer 20

Edema
Throbbing, burning, or pain at the site
Increased skin temp
Erythema
Red line up arm w/ a palpable band at the vein site
Slowed infusion

Question 21

What are treatments for phlebitis/ thrombophlebitis?

Answer 21

Promptly d/c infusion & remove catheter
Elevate extremity
Document size of infiltrated area/ estimate Amt of fluid present/ monitor site
Apply a cold compress to minimize the flow of blood, then a warm compress to increase circulation
Check w/ provider to see of still needed.

Question 22

What finding is indicative of phlebitis?

Answer 22

Palpable hard mass above insertion site

Pain at site

Question 23

What will minimize the risk of a catheter embolism?

Answer 23

Avoid reinserting the needle into an IV catheter.

Question 24

What are indicative findings of fluid overload?

Answer 24

SOB,
Crackles in lungs
Distended neck veins

Question 25

What is true when initiating IV therapy for an older adult?

Answer 25

Distended the veins by using a BP cuff. Do not use a tournique

Question 26

What does intravenous therapy consist of?

Answer 26

It involves administering fluids via a IV catheter for the purpose of providing medications, supplementing fluid intake, or giving fluid replacement , electrolytes, or nutrients.