Quiz 4- Perfusion, Tissue Integrity, & Safety Flashcards
List 4 complications that can arise from a peripheral IV
Phlebitis
Infiltration
Air embolism
Extravasation
infection
hypervolemia
The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action?
Obtain new IV tubing
The nurse should obtain new IV tubing because contamination has occurred and could cause systemic infection to the client.
After changing the intravenous tubing on a patient’s primary infusion, the nurse notes air bubbles in the tubing. How should the nurse remove them?
Close the clamp, stretch the tubing downward, and flick the tubing
The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride and needs to add the medication to the IV bag. The nurse should plan to take which action immediately after injecting the potassium chloride into the port of the IV bag?
Rotate the bag gently
After adding a medication to a bag of IV solution, the nurse should agitate or rotate the bag gently to mix the medication evenly in the solution. The nurse should then attach a completed medication label. The nurse can then prime the tubing.
The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client’s intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which complication has occurred?
Infiltration
An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling are the results of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and start a new IV line at another site
When administering an IV piggyback medication to infuse by gravity, how can the nurse ensure that the medication will infuse properly?
Hang the piggyback medication higher than the primary fluid
Placing the secondary bag higher than the primary fluid will allow for the fluid to infuse at a faster rate than the primary bag with the help of gravity.
The nurse is starting a client’s 3rd unit of PRBCs. The client begins complaining of severe back pain, becomes apprehensive, and VS: T 100.9F, P 126, RR 28, BP 80/54. Which intervention should the nurse perform as priority?
Stop the infusion
the client is having a blood transfusion reaction and the nurse must stop the infusion immediately.
Which signs alert the nurse to a potential complication of an IV push? Select all that apply.
The client presents with labored breathing after the push
The nurse observes clear liquid ooze from the IV insertion site
The nurse assesses that the insertion catheter will not flush
clear fluid oozing around the IV catheter insertion site indicates something is wrong with the IV site. If the nurse assesses that the catheter will not flush, she should check for kinks in the catheter tubing and do not forcefully flush the IV catheter. Labored breathing after a push of med can mean an adverse reaction is occurring.
The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item?
Vital signs
A change in vital signs during the transfusion from baseline may indicate that a transfusion reaction is occurring. This is why the nurse assesses vital signs before the procedure and again after the first 15 minutes.
The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next?
Run normal saline at a keep-vein-open rate
If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-vein-open rate pending further health care provider prescriptions. This maintains a patent IV access line and aids in maintaining the client’s intravascular volume.
The nurse who is about to begin a blood transfusion knows the blood cells start to deteriorate after a certain period of time. Which item is important to check regarding the age of blood cells before the transfusion is begun?
Expiration date
The nurse notes the expiration date on the unit of blood to ensure that the blood is fresh. Blood cells begin to deteriorate over time, so safe storage usually is limited to 35 days. Careful notation of the expiration date by the nurse is an essential part of the verification process before hanging a unit of blood.
A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain with intravenous (IV) solution from the IV storage area to hang with the blood products at the client’s bedside?
0.9% sodium chloride
The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question?
“Have you ever had a transfusion before?”
Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client’s temperature before hanging the blood transfusion and records 100.60 F orally. Which action should the nurse take?
Delay hanging the blood and notify the health care provider (HCP)
If the client has a temperature higher than 1000 F, the unit of blood should not be hung until the HCP is notified and has the opportunity to give further prescriptions.
The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring?
15 minutes
The nurse must remain with the client for the first 15 minutes of a transfusion, which is usually when a transfusion reaction may occur. This enables the nurse to detect a reaction and intervene quickly.
When choosing a site for the IV catheter, which statement(s) is/are true?
The nurse will choose a vein that is not visibly hard or scarred
The nurse and client will collaborate on choosing an appropriate site
The nurse will attempt to choose a site to maximize client mobility
This answer is correct because often the client knows which veins are easily accessible and can advise the nurse. The collaboration between the client and the nurse can increase access to a functional site. Many clients prefer the IV not be placed in the dominant hand, so they can continue to maximize mobility as much as possible while hospitalized. The nurse should choose a vein that is not visibly hard or scarred. Patients should not care for their own IV site.
What is the correct order of the steps for starting an IV on a client? Place steps in appropriate order.
A. Perform hand hygiene, don gloves, open the IV extension set and prime the set with sterile saline.
B. Apply the tourniquet above the site chosen and clean the site.
C. Open the catheter and hold it securely while inserting the catheter into the chosen vein.
D. When a flash of blood is observed, insert the catheter fully into the vein, and remove the cannula.
E. Attach the IV extension set and assure placement by drawing blood into the IV extension set via the saline syringe, then flush.
F. Continuing to hold the catheter in place, apply a clear transparent dressing so the site is visible.
G. Place initials, date, and time on the IV transparent dressing
A, B, C, D, E, F, G
A healthcare provider’s prescription reads levothyroxine (Synthroid), 150mcg orally daily. The medication label reads Synthroid, 0.1mg/tablet. The nurse administers how many tablet(s) to the client?
1.5 tablets
First, convert 150mcg to milligrams. In the metric system, to convert smaller to larger, divide by 1000 or move the decimal three places to the left. Therefore, 150mcg = 0.15mg. Next, use the formula to calculate the correct dose:
(Desired/Available) x Tablet = Tablets per dose
(0.15mg/0.1mg) x 1 tablet = 1.5 tablets
A healthcare provider prescribes heparin sodium, 1300 units/hour by continuous IV infusion. The pharmacy prepares the medication and delivers an IV bag labeled heprain sodium 20,000 units/250mL D5W. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 1300 units/hour? Record the answer to the nearest whole number.
16 mL/hour
First, you need to determine the amount of heparin sodium in 1mL. The next step is to determine the infusion rate, or milliliters per hour.
Step 1:
Known amount of medication in solution/ Total volume of diluent = Amount of medication per milliliter
20,000 units/250mL = 80 units/mL
Step 2:
Dose per hour desired/Concentration per milliliter = Infusion rate, or mL/hour
1300 units/(80units/mL) = 16.25 or 16 mL/hour
A health care provider’s prescription reads to administer an IV dose of 400,000 units of penicillin G benzathine (Bicillin). The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine (Bicillin), 300,000 units/mL. The nurse prepares how much medication to administer the correct dose? Record your answer using one decimal place.
1.3 mL
Desired x mL/ Available = Milliliters per dose
400,000 units x 1mL / 300,000 units = 1.33 = 1.3 mL
A health care provider’s prescription reads morphine sulfate, 8mg stat. The medication ampule reads morphine sulfate, 10mg/mL. The nurse prepares how many milliliters to administer the correct dose?
0.8 mL
Desired x mL/ Available = Milliters
8mg x 1mL / 10mg = 0.8mL
Cefuroxime sodium, 1g in 50mL normal saline, is to be administered over 30 minutes. The drop factor is 15gtt/mL. The nurse sets the flow rate at how many drops per minute?
25 gtt/minute
Total volume x Drop factor/ Time in minutes = Drops per minute
50mL x 15gtt/ 30 minutes = 25 gtt/minute
The same IV orders above (500 mL NS over 5 hours) will have how many mL left in the IV bag after 3 hours?
200 mL
500mL/5hr = 100 mL/hr x 3hr = 200mL
A health care provider prescribes regular insulin, 8 units/hour by continuous IV infusion. The pharmacy prepares the medication and then delivers an IV bag labeled 100 units of regular insulin in 100mL normal saline. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 8 units/hour?
8 mL/hour
First, you need to determine the amount of insulin in 1mL. The next step is to determine the infusion rate (mL/hr)
Step 1:
Known amount of medication in solution/Total volume of diluent = Amount of medication per milliliter
100 units/100mL = 1 unit/mL
Step 2:
Dose per hour desired/Concentration per milliliter = Infusion rate (mL/hour)
8 units / (1 unit/mL) = 8 mL/hour.
Order for 500 mL of 0.45NS is to infuse over 8 hours. Calculate the flow rate
63mL/hr
