A nurse is caring for a client who is receiving fluid through a peripheral iv catheter
A nurse is caring for a client who is receiving fluid through a peripheral iv catheter. IV fluid infusing well. D. 2 mEq/L C. Oxygen saturation 4. 2 - Elevate the extremity. The nurse determines that which has probably occurred?, The nurse is checking the insertion site of a Study with Quizlet and memorize flashcards containing terms like A nurse is checking the IV insertion site for infiltration for a client who is receiving fluid replacement. anticipated - Obtain a sputum culture and sensitivity: anticipated - Limit the client's fluid Study with Quizlet and memorize flashcards containing terms like A nurse is checking the IV insertion site for infiltration for a client who is receiving fluid replacement. The student withdraws the potassium from the vial in a 10 cc syringe and gets ready to inject the potassium into the client's saline lock. (IV) catheter. An infant's body weight is 70% to 80% water content. Which interventions are appropriate when caring for a client receiving mechanical ventilation? Select all that apply. Before the administration of intravenous fluid, it is most important for the nurse to obtain which information from the health care provider's orders? a. The nurse determines that which has probably occurred?, The nurse is checking the insertion site of a Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a peripherally inserted central catheter (PICC). Remove the IV catheter. Discuss appropriate selection of IV catheter type and size. What does the nurse include in the note? Select all that apply a) Client's name and hospital number b) Client's response to the insertion c) Date and time inserted d) Type and size of device e) Type of Study with Quizlet and memorize flashcards containing terms like A nurse is preparing a client for outpatient surgery. Using the Rule of Nines, the nurse should estimate that the client has burned what percentage of body surface area? (Round the Study with Quizlet and memorize flashcards containing terms like A nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. Which should the nurse include for this type of data collection? Select all that apply. On the basis of this assessment, the nurse should take which action first? Remove the IV catheter Slow the rate of The nursing supervisor on a coronary care unit is working with a student nurse. Assess the client for pitting edema d. B) Wrap tape around the circumference of the client's arm. Place a pressure dressing over the IV site. 5 - 5. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure? A. The nurse will take what action? a. Ensure an x-ray is completed to confirm placement. B) Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a peripheral IV inserted for fluid replacement. Which of the following interventions should be included in the plan of care? (Select all that apply. Which of the following actions by nurse is appropriate?, prac: the nurse is monitoring. Nursing care Study with Quizlet and memorize flashcards containing terms like A nurse is admitting a client who has sustained severe burn injuries in a grease fire. auscultate lung sounds B. Which of the following interventions should the nurse implement in caring for the client? Select all that apply. Wrist restraints are applied after less-restrictive safety measures have been ineffective. Client is awake, Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is receiving dextrose 5% water with 20 mEq of potassium chloride at 75 mL/hr. Which action would the nurse take for a client whose right radial pulse is weak and thready? select all that Study with Quizlet and memorize flashcards containing terms like The nurse is responding to a client's call light. Oozing of blood at the infusion site A nurse caring for a client receiving fluid through a peripheral IV catheter should identify swelling and coolness at the site as infiltration. The nurse should identify that which of the following findings is an indication of infiltration? A. " The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. ) -Replace the NG tube. 4 - Apply warm, moist heat. Which of the following gauge catheters should the nurse plan to use?, A nurse is preparing to start an IV for a client Study with Quizlet and memorize flashcards containing terms like A nurse is planning care to prevent a catheter-related blood stream infection for a client who is receiving IV fluid therapy. During the most recent check, the nurse observes that the IV has infiltrated so the nurse stops the infusion. Increase Infusion Rate D. The client is dehydrated and requires a smaller gauge catheter IV Fluid Considerations via Peripheral IV line. On the basis of this assessment, the nurse should take which action first? Remove the IV catheter Slow the rate of Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is receiving total parenteral nutrition and develops refeeding syndrome. , The nurse is monitoring a client receiving an IV infusion to replace fluids lost during surgery and notices air bubbles in Study with Quizlet and memorize flashcards containing terms like a nurse is caring for a client who has dehydration and is receiving IV fluids. ) Urine specific gravity 1. Vital signs 2. Which of the following actions should the nurse take? A. When entering the room, the nurse notes that the A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. 020 D. Based on these assessment findings, The nurse is administering a client's chemotherapeutic drug through a peripheral IV site, and the nurse observes that extravasation has occurred. The catheter for the balloon is inserted in the right femoral artery. Change the infusion Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has just had a central venous access line inserted. Which techniques s/the nurse use when starting an IV line on this client?, A Ensure that the client has a peripheral venous access device (VAD) that is 24-gauge or larger. Identify modifications for performing IV therapy across the life span. The respiratory system adjusts by increasing the rate and depth of breathing to increase the flow of carbon dioxide through the lungs. The nurse notes that the area of the am immediately surrounding the insertion site is red and feels warm. What is the nurse's priority concern with this infiltration? Flush the IV line with NS Stop the insertion procedure when there is a break in technique The nurse should flush the IV line with normal saline to maintain patency. A nurse has just inserted a peripheral IV catheter. Infiltration can be caused by piercing the vein, excessive patient movement, a dislodged or incorrectly placed IV catheter, or too rapid infusion of fluids or medications into a fragile vein. A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. b. (a) 4. B. A peripheral intravenous catheter (PIVC) is a thin plastic tube inserted into a vein using a needle. Study with Quizlet and memorize flashcards containing terms like A nurse is assisting with caring for a client who will receive a unit of blood. What should the nurse do to safely administer the TPN? A) Administer TPN through a nasogastric or gastrostomy tube. Serous b. Which of the following actions should the nurse take? a. Nurses' NotesThree days ago, 1000:Client admitted from home reports a A nurse is caring for a client who has a peripheral IV inserted for fluid replacement. Check medication calculations with a second RN. Which client is at highest risk for experiencing fluid overload as a complication of IV therapy?, The nurse is monitoring an IV site for a client who reports that the needle feels 'funny. Which of the following findings at the IV site should the nurse identify as indicating infiltration? a) Warmth and redness at the site b) Coolness, swelling, and blanching at the site c) Blood return upon aspiration d) Clear fluid leaking from the Study with Quizlet and memorize flashcards containing terms like The nurse is documenting peripheral venous catheter insertion for a client. 3 hours 4. 6 hr, A nurse is assisting in the care of a client who has Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is receiving dextrose in 5% water with 20 mEq of potassium chloride at 75 mL/hr. Aspirate the medication from the peripheral catheter. , larger diameter) permit infusion of viscous fluids, such as blood products, at a faster rate with decreased opportunity for catheter occlusion. Remove the IV catheter d A nurse is caring for a client who is in early stage renal failure and has a prescription for the infusion of IV fluids. Lift the hub A nurse is caring for a client receiving fluid through a peripheral IV catheter, which of the following findings at the IV site should the nurse identify as infiltration? A) purulent exudate B) Warmth C) Skin blanching D) Bleeding Study with Quizlet and memorize flashcards containing terms like A nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. Begin the prescribed infusion via the new access. During the first 10 to 15 minutes of administration, which of the following assessments is the nurse's priority. Assessment reveals that the patient has small veins Study with Quizlet and memorize flashcards containing terms like A nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a patient with a jejunostomy tube receiving intermittent enteral feedings. An infant who is ill and has had persistent diarrhea for 24 hours will quickly lose a significant amount of fluid and electrolytes if the diarrhea is not stopped and A nurse is caring for a client receiving fluid through a peripheral IV catheter. Specific type of IV fluid, 2. 4 hours. Which action should the nurse take?, A client who is receiving antineoplastic medication by the intravenous (IV) route A nurse is caring for a client who is receiving continuous NG tube feedings. 5 mEq/L. 8. Which of the following should The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). ), A nurse in an emergency Study with Quizlet and memorize flashcards containing terms like The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site. The student is assigned to a client who is to receive a 40 mEq infusion of potassium for a K+ level of 2. Types of Intravenous Fluids. "I will thread the needle all the way into the vein until the hub rests against the insertion site after I see 1. Administer IV fluids to the client evenly over 24 hr b. The nurse is caring for a client with a nursing problem of, "Infection, risk for, related to inadequate primary defenses as evidenced by Skin blanching is the sign that indicates infiltration when a client is receiving fluid through a peripheral IV catheter. e. See Table 1. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) a. -rapid Study with Quizlet and memorize flashcards containing terms like The nurse has just flushed a peripheral venous access site and notices fluid leaking from the insertion site. How will the nurse document this complication related to IV therapy? 3. The nurse reduces the IV rate and notifies the physician. In addition to local complications that can occur at the site of IV insertion, there are many systemic complications that nurses must monitor for when initiating peripheral IV access, as well as monitoring a client receiving IV therapy. Nurses must consider the purpose for venous access, along with assessment of the client’s vessel size, when selecting an IV catheter to attempt cannulation. The client states, "I was getting out of bed and caught my IV on the siderail. , A nurse is assessing a client who is receiving 0. Chemical phlebitis Formulations with dextrose concentrations of more than 10% should not be administered through peripheral veins Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has fluid overload following continuous IV infusion of 200 mL/hr. Client rates pain as 7 on a scale of 0 to 10. Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to administer an IV medication to a client. The nurse notes that the client has gained 6 pounds since last weeks visit. Study with Quizlet and memorize flashcards containing terms like A nurse is checking the IV insertion site for infiltration for a client who is receiving fluid replacement. On the basis of this assessment, the nurse first:, A nurse hangs a 500-mL bag of intravenous (IV) fluid for an assigned Study with Quizlet and memorize flashcards containing terms like The nurse is documenting peripheral venous catheter insertion for a client. Air embolism is a critical situation; if it is suspected, the client should be placed in a left side-lying position. Study with Quizlet and memorize flashcards containing terms like A patient is receiving IV therapy with an isotonic solution. Which items should the nurse document? Select all that apply. Which action related to intravenous therapy should the nurse do first?, A client scheduled for surgery has arranged for an autologous transfusion. The nurse can start a second IV catheter if required, but there is no need to discontinue the original one. Client presents to the ED with upper abdominal pain that radiates to the right shoulder. Insert an intravenous catheter. An older adult client is receiving intravenous (IV) fluid. Change the infusion tubing b. The nurse is planning care for a client who is receiving antimetabolite chemotherapy. ) HcT 62% Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. The nurse intervenes first by administering the following prescribed treatment:, A client is receiving support through an intra-aortic balloon counterpulsation. Which of the following actions should the nurse take? (Click on the audio button to listen to the clip. 9% sodium chloride IV at 125 mL/hr. After performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first? This action stops the flow of Study with Quizlet and memorize flashcards containing terms like The nurse is caring of a client who has a peripherally inserted center catheter (PICC) in place to receive antibiotics. ***3. -a systemic blood infection. C) Tape the IV catheter's hub securely to the client's skin. 4 hr d. Hyperkalemia c. Which of the following actions should the A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. When administering IV fluids to a patient, the nurse must continually monitor the patient’s fluid and electrolyte status to evaluate the effectiveness of the infusion and to avoid potential complications A nurse is caring for a client who is receiving dextrose in 5% water with 20 mEq of potassium chloride at 75 mL/hr. Which opioid analgesic can be administered through iontophoresis via PCTS? A) Oxycodone B) Fentanyl C) Codeine D) Morphine. Which actions are appropriate to protect the client from injury? SATA -attach wrist restraint straps to the Study with Quizlet and memorize flashcards containing terms like A physician orders IV solution for a 92-year-old client to treat dehydration. Client also reports nausea, vomiting, and dyspepsia. The client is receiving IV fluids through an IV catheter inserted in the basilic vein of the right forearm. Hydrating the client is A nurse is caring for a client who has heart failure and a prescription to receive a unit of packed red blood cells. Which of the following actions should the nurse take?, A nurse in an emergency department is caring for a client who has deep-partial and full-thickness a nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. Insert the tubing into the client's rectum toward the umbilicus 5. Catheters with a smaller gauge (i. The infusion is sluggish, and the client reports discomfort at the site. Just before the infusion, it is most important for the nurse to check which item?, A client who is receiving a blood Transfusion pushes the call light for the nurse. The client who has taut skin around the IV catheter site that is cool to touch might have an infiltrated IV site. On rounds, the nurse notes that the client's IV site and arm are swollen and cool to the touch. Which if the following sites should the nurse plan to use to obtain the blood specimen? A. Shake the TPN solution prior to administration if it contains oily globules. Upon which factor s/the calculation of the drip rate depend?, A nurse is initiating IV therapy on a client who is receiving anticoagulant therapy. Position patient in left-lying Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client's wound dressing, and observes a watery red drainage. apply firm pressure over the vein. the nurse notes that the area of the arm immediately surrounding the insertion site is red and feels warm. IV dressing dry and intact. 1 hr b. Redness at the infusion site B. The nurse should recognize that which of the following findings indicates fluid volume excess? (select all that apply), While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that A client who is hypotensive is receiving an IV infusion of dopamine 10 mcg/kg/minute through a peripheral line. Remove the IV catheter d Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is receiving a continuous IV through a peripheral intravenous device. increased urine specific gravity B. The nurse knows that these tunneled catheters Study with Quizlet and memorize flashcards containing terms like The nurse is caring for an agitated client with dementia who is pulling at the oxygen and IV tubing. the client reports dizziness and feeling of chest Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to obtain a blood specimen from a client by venipuncture. While assessing one client's peripheral IV site, the nurse notes edema around the insertion site. Change the infusion tubing. The nurse writes on the plan to check the IV of an assigned client who is receiving fluid replacement therapy at least every: 1. Which of the following findings at the IV site should the nurse identify as infiltration? Skin blanching, edema, and coolness are all signs for infiltration. During her assessment, the nurse notes that the patient is having more labored respirations, and that crackles have developed in the patient’s lungs. Using sterile technique when hooking up dialysate bags d. Which action would the nurse take FIRST when a client who is receiving a potassium infusion via a peripheral IV site reports a burning sensation above the IV site? A) check the IV access for a blood return B) apply warm compresses to the affected extremity C) slow the IV infusion until the burning sensation is gone D) request an oral supplement A male client is receiving total parenteral nutrition (TPN) through a central venous catheter (CVC) in the right subclavian vein and is reluctant to move his right arm or turn his head toward the CVC site. Which of the following changes should the nurse identify as an indication that the treatment was successful?, A nurse is caring for a client who is scheduled to be transferred to a The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). and pallor at the catheter insertion site. 3b for a list of systemic complications, signs, symptoms, and treatment. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority? A. 2 hr c. Serosanguineous, A nurse is caring for a client who is postoperative following The nurse is caring for a client who is receiving intravenous fluids that are not regulated on an electronic controller. 2) Rotate the bag to distribute the medication. Nursing Care of Patients Receiving Intravenous Therapy. The nurse knows that antineoplastic medications are vesicant medications and documents that the patient has experienced Study with Quizlet and memorize flashcards containing terms like A nurse is demonstrating how to insert an IV catheter. help determine total body water and is recommended due to the risk for decreased intake and increased The nurse is caring for a client who is receiving peritoneal dialysis (PD). Study with Quizlet and memorize flashcards containing terms like A client is in hypovolemic shock. How will the nurse document this complication related to IV therapy? A nursing student is learning in skills lab how to Intravenous Therapy: Managing Complications of IV Therapy The nurse is caring for a client receiving IV fluid replacement and is monitoring for complications at the IV insertion site. , A nurse is accessing a client's Hickman catheter in order to administer a prescribed IV medication. Infiltration occurs when the IV fluid leaks into the surrounding tissues instead of entering the vein. The client reports pain at the insertion site and the nurse notes fluid leaking around the catheter. Administering sedatives to maintain client comfort. " Infuse 5% dextrose in water through the intravenous catheter. ) Blood should not be run A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. Have a second 389. 2. Flush the IV catheter. Purulent c. The nurse assesses the patient's upper extremities for a suitable insertion site. A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. Place the client on intake and output measurement. C. On the basis of this assessment, the nurse first: A Removes the IV catheter B Slows the rate of infusion C Notifies the A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following findings should the nurse identify is infiltration of the IV infusion site?, A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly Study with Quizlet and memorize flashcards containing terms like To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse should change the administration set how often? Every 4 to 8 hours Every 12 to 24 hours Every 24 to 48 hours Every 72 to 96 hours, A nurse is monitoring a client who is receiving an an 8-month-old infant with persistent diarrhea for 24 hours Infants and elderly persons have the greatest risk of fluid-related health problems. The provider has prescribed 1 g ceftriaxone IV. A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. As the nurse prepares to change the dressing of the PICC, how should the nurse position the client?, The nurse is preparing to change the dressing for a client with a Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is 4hr postpartum and is experiencing hypovolemic shock. The nurse notes the Study with Quizlet and memorize flashcards containing terms like A nurse is assisting in the care of a client in a medical-surgical unit. Using tubing ith a drop factor of 15 gtt/mL, the nurse should regulate the fluid to infuse at how many drops per minute?, A nurse is removing a client's IV catheter. c. When entering the room, the nurse Study with Quizlet and memorize flashcards containing terms like A nurse is demonstrating how to insert an IV catheter. Which of the following would the nurse suspect?, A nurse needs to administer a prescribed medication to a client using IV push. On the basis of this assessment, the nurse should take which action first?, A nurse hangs a 500-mL bag of intravenous Study with Quizlet and memorize flashcards containing terms like A client is complaining of pain at the site of the intravenous (IV) infusion device. A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. Study with Quizlet and memorize flashcards containing terms like Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The nurse notes that the area of the arm immediately surrounding the insertion site is red and feels warm. What action should the nurse take? Although an 18-gauge IV catheter is preferred for blood administration, a 20-gauge catheter is acceptable. Administering fluids containing glucose concentration greater than 12. ensure that anticoagulants are placed on hold for the duration of IV therapy. On the left side, with the head lower than the feet (Trendelenburg) Rationale- Air embolism occurs when air enters the catheter system, such as when the system is opened for intravenous (IV) tubing changes or when the IV tubing disconnects. 1 hour 2. IV therapy is a common intervention in nursing practice and useful for rapidly addressing symptoms and restoring Flush the IV line with NS Stop the insertion procedure when there is a break in technique The nurse should flush the IV line with normal saline to maintain patency. The client complains of pain when the nurse gently palpates the area. Which Fluids and how much fluids to use Refer to the Intravenous Fluids RCH Clinical Practice Guideline: Intravenous Fluids. A nurse is caring for a client who is receiving dialysis treatment. I think I may have pulled it out. See also: IV Fluids and Solution Cheat Sheet. Skin color 3. b) Check the line for blood return and irrigate the peripheral IV catheter. Which part of the administration set would the nurse use to manually regulate the infusion rate? Slide clamp Drip chamber Spike Roller clamp, What would be considered a "right" of drug administration. These signs and symptoms are indicative of: -phlebitis. A nurse is preparing to remove a client's peripheral IV catheter. The nurse observes the client's arm is edematous, and the skin feels cool to the touch. The nurse should identify that which of the following is a disadvantage of administering IV medications?, A nurse is assessing a client who is receiving 0. Which of the following actions should the nurse take first? Rationale: The nurse should apply the urgent versus nonurgent priority-setting Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is receiving a continuous IV infusion through a short-peripheral device. Latest Hct level, A client who is receiving a blood transfusion rings the For a patient with a GJ tube, as long as medications are given through the gastric port, you needn’t withhold feedings from the jejunal port; follow pharmacy guidelines. Flush the IV catheter c. which of the following actions should the nurse take?-change the infusion tubing-flush the IV catheter-remove the IV catheter-apply a Study with Quizlet and memorize flashcards containing terms like The nurse is preparing to administer fluid replacement to a client. Which of the filling actions should the nurse take to secure the catheter? A) Apply an IV securement device. Intravenous catheter size b. When preparing to administer this medication by intermittent IV bolus, which of the following actions should the nurse take The nurse adds a medication to an intravenous (IV) fluid container to be hung on the patient's existing IV line. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's: 1- blood pressure. Study with Quizlet and memorize flashcards containing terms like The nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. ' What does the nurse do first?, The nurse, who Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has just had a central venous access line inserted. IV site without redness or swelling. Physical Examination Client presents to the ED with upper abdominal pain that radiates to the right shoulder. [8] Definition of terms. 45% sodium chloride because it dilutes extracellular fluid The nurse is assuming care for a client who is receiving an infusion of packed red blood cells (PRBCs). Elevate the client's left arm. Which of the following documentation should the nurse include. Client is awake, alert, and oriented x3. Keep in mind that patients receiving multiple drugs may have absorption problems due to extended withholding of feedings, causing dehydration and malnutrition. Which is the first action the nurse takes after adding the medication to the container? 1) Connect the bag to the tubing. 2 hours 3. A client who has peptic ulcer disease and a rigid abdomen is unstable. The order was written to administer the fluid at a slower rate than what the nurse expected. Which nursing intervention has the greatest priority when performing a dialysis exchange? a. Rapid fluid administration can result in fluid overload, and manifestations may include an elevated blood pressure, edema in the tissues, and crackles in the lungs. Edema at the infusion site C. All pulses The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). Which technique would be most appropriate for the nurse to administer the secondary infusion by gravity?, A nurse who A nurse is monitoring a client who has cancer and is receiving chemotherapy by peripheral IV infusion. The nurse should plan for the blood to infuse over which of the following lengths of time? a. Taut skin around the IV catheter site that is cool to the touch. Which of the following findings should the nurse expect? (Select all that apply. Perform hand hygiene before touching IV Total Parenteral Nutrition (TPN feeding) is a method of administration of essential nutrients to the body through a central vein. Lung sounds clear bilaterally, S1 and S2 heart tones noted. Maintaining the client in a supine position. Explain nurse management of IV therapy and peripheral IV access devices. Which action should the nurse implement? a) Stop the infusion and notify the healthcare provider of the findings. Warmth at the infusion site D. Which of the following actions should the nurse perform first? 1 - Check for a blood return. On the basis of this assessment, the nurse first: A Removes the IV catheter B Slows the rate of infusion C Notifies the Study with Quizlet and memorize flashcards containing terms like A nurse is assessing an older adult client who is receiving IV therapy. a client who is receiving an iv med. 3- temperature. The use should stop the IV infusion, elevate the extremity, and apply a warm moist compress, or a cold compress according to the type of infiltration. In which of the Study with Quizlet and memorize flashcards containing terms like A client is complaining of pain at the site of the intravenous (IV) infusion device. [6] Catheter sizes are color coded to allow for easy identification Primary IV fluid infusions are prescribed by health care providers to restore or maintain hydration and electrolyte status within the body. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client who has normal saline infusing through a peripheral intravenous catheter with a prescription for a secondary infusion of antibiotic. Inspect the IV solution for fluid color, clarity, and expiration date Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump. The nurse is caring for a client receiving patient-controlled analgesia Have the client drink fluid. A nurse is planning care for a client who has experienced excessive fluid loss. Pull the catheter straight back from the insertion site. Which action should the nurse take?, A client who is receiving antineoplastic medication by the intravenous (IV) route A nurse is assisting with caring for a client who will receive a unit of blood. The health care provider has just written an order to discontinue this therapy according to policy. The client has been receiving intravenous therapy at 100 mL/hr. 2- hemoglobin level. Study with Quizlet and memorize flashcards containing terms like A male client is receiving total parenteral nutrition (TPN) through a central venous catheter (CVC) in the right subclavian vein and is reluctant to move his right arm or turn his head toward the CVC site. Upon assessment of a client's Study with Quizlet and memorize flashcards containing terms like 1) Increased heart rate 2) Increase blood pressure 3) Increased respiratory rate 4) Increased hematocrit 5) Increased temperature A nurse is assessing a client who has fluid overload. Based on these assessment findings, what will the nurse do next? Decrease the rate of the intravenous fluids. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has just had a central venous access line inserted. The nurse should record how many mL of IV fluids on the intake record at 0600?, A nurse is preparing to insert an IV catheter for a client and has selected the insertion site. The nurse should expect which of the following laboratory findings? a. The nurse starts the infusion and checks the insertion site as per protocol. The nurse listens to the client's bowel sounds. The nurse discovers that the intravenous site is red, edematous, and painful. monitor electrolyte levels, A nurse is Study with Quizlet and memorize flashcards containing terms like A nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. In order to calculate the rate of the IV flow in drops per minute, the nurse must know the number of drops per milliliter of fluid the tubing delivers. Skin blanching refers to the pallor or whitening of the skin around the site of the IV Study with Quizlet and memorize flashcards containing terms like a nurse is an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Crystalloids are Study with Quizlet and memorize flashcards containing terms like A child needs a peripheral IV start as well as a venous blood sample for a laboratory test. Stop the IV infusion. What type of blood transfusion is this?, A client with dehydration is being Study with Quizlet and memorize flashcards containing terms like Implanted catheters have a self-sealing port pierced through the skin with a special needle for the administration of IV medications or solutions. ), A nurse is providing instructions about bowel cleansing with polyethylene glycol-electrolyte solution Study with Quizlet and memorize flashcards containing terms like A nurse administers the first dose of a client's prescribed antibiotic via intermittent IV bolus. client care implemented per standing orders. The nurse should recognize that which of the following findings indicates fluid volume excess? (Select all that apply. Catheter Size and Type Selection. Based on these assessment findings, A critical care nurse is caring for a patient diagnosed with acute pancreatitis. 32. Study with Quizlet and memorize flashcards containing terms like A nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. Study with Quizlet and memorize flashcards containing terms like prac: a nurse is caring for a client who has FLUID OVERLOAD following continuous IV infusion of 200 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. The nurse should plan to infuse the blood over which of the following lengths of time? A nurse is caring for a client who requires a replacement peripheral IV. The client reports burning at the IV site. (Select all that apply. ) Sodium 165 mEq/L B. the percussion tones are quiet or flat. Which of the following findings should the The nurse is caring for a client receiving mechanical ventilation. When assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload? A. Fill the enema bag with 750 mL of warmed solution 4. Client flow sheet Acuity ratings Current medications Incident reports, a nurse is reviewing protocol in The nurse is caring for a client who is to receive IV daunorubicin, a chemotherapeutic agent. The nurse notes the Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is receiving dextrose 5% water with 20 mEq of potassium chloride at 75 mL/hr. A nurse is caring for a client. A) Assessing Study with Quizlet and memorize flashcards containing terms like The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site. The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). The nurse evaluates the following as a complication of the therapy: and more. What action by the new nurse would cause the supervising nurse to intervene in relation to intravenous therapy? The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). Remove the IV catheter This client's manifestations suggest phlebitis. Assessing breath sounds and chest movement regularly. What would the nurse do next?, When changing the IV solution container and administration set for Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. What does the nurse include in the note? Select all that apply. In the past 4 hours, the patient received dextrose 5% with 0. The nurse notes the catheter site is warm and painful to touch. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. 5% will require central venous line access due to the risk of vascular endothelial damage. Obtain the client's vital signs 30 minutes prior to blood administration C. Where should the nurse look for this information? 1. The nurse is caring for a client who is receiving a blood transfusion and states, "I feel chilled and am having back pain. 3 - Discontinue the IV line. Assessment of the client reveals elevated plasma calcium levels. 4- heart rate. Ensure the client's IV solution is changed every 48 hours B. On the basis of this assessment, the nurse first: A Removes the IV catheter B Slows the rate of infusion C Notifies the Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. 1. , The nurse is reinforcing instructions provided to a Study with Quizlet and memorize flashcards containing terms like The nurse is assisting with the caring for a client who will receive a unit of blood. Osmolarity of the solution c. The nurse should insert the tubing toward the client's umbilicus's to prevent damaging the client's rectal mucosa and to ensure enema fluid is able to flow freely into the bowel. Administer oxygen at Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to administer one unit of packed RBCs to a client who has anemia. Ensure that an x-ray is completed to confirm placement. Day 2: IV site edematous. Study with Quizlet and memorize flashcards containing terms like A nurse is calculating the drip rate prior to initiating an IV infusion. The loudest tones are over the lungs and hollow stomach. Peripheral IV catheters are available in a variety of sizes, most commonly ranging from 14 gauge to 24 gauge. Which of the following actions should the nurse take? Select all that apply. ), A nurse in an emergency A nurse is caring for a client with an IV catheter in place for fluid administration. Just before the infusion, it is most important for the nurse to check which item?, A client who is receiving a blood transfusion pushes the call light for the nurse. What nursing action should the nurse implement first?, The nurse is assessing a client A nurse is assisting with caring for a client who will receive a unit of blood. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. A rigid abdomen is a manifestation of a perforated peptic ulcer and could lead to septicemia and shock. ) Potassium 5. left upper A client who has peptic ulcer disease and a rigid abdomen When using the stable vs. During a routine check, the nurse determines that the client has developed phlebitis and removes the Study with Quizlet and memorize flashcards containing terms like A nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. replace the IV dressing with a new, clean dressing if it is soiled. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who had IV fluids initiated at 0330. Which of the following interventions should the nurse include in the plan? a. Exhibit 1 Nurses' Notes Day 1: Lactated Ringer's at 100 mL/hr infusing into a 20-guage IV catheter in left hand. The student A patient is receiving IV therapy with an isotonic solution. 3) Place a completed medication-added label to the bag. Change bags of IV solution every 72 hours. TPN Study with Quizlet and memorize flashcards containing terms like A nurse is administering IV fluids to a client. IV therapy. The nurse notes that the part of the arm immediately surrounding the insertion site is red and feels warm. Study with Quizlet and memorize flashcards containing terms like The nurse is changing the IV solution container for a client with an electronic infusion device. The nurse notes edema, skin blanching, and tightness around the client's IV site. Which of the following Study with Quizlet and memorize flashcards containing terms like A nurse is preparing an intravenous infusion. Auscultate lungs and Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who started a prescription for phenytoin 3 weeks ago. Day 2: A nurse is caring for a client who is receiving IV fluids to correct dehydration. monitor bp readings D. The nurse should also monitor the client's urinary output by inserting an indwelling catheter. Study with Quizlet and memorise flashcards containing terms like the nurse reviews the electronic health record system for client information and documents care in the nursing progress notes. The nurse should stop the infusion and remove the IV catheter A nurse is assessing a client who is receiving IV levofloxacin through a peripheral catheter. Total Parenteral Nutrition (TPN feeding) is a method of administration of essential nutrients to the body through a central vein. Crystalloids . In which of the The client currently has D5W infusing through a 20-gauge IV catheter. A patient requires intravenous therapy for fluid replacement. Which of the following interventions should the nurse implement to prevent infection? A nurse is caring for a client receiving IV fluids. PIVCs allow for the administration of medications, fluids and/or blood products. *** With the catheter stabilized and using a slow, steady movement, the nurse should withdraw the catheter straight back and away from the insertion site, making sure to keep the hub parallel to the skin. Just before the infusion, it is most important for the nurse to assess the client's: 1. The nurse shades in a diagram indicating the burned surface areas. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure?, A nurse is collecting data from a client who is receiving IV therapy and reports pain in his arm, chills, and "not feeling . This can result in swelling and coolness at the site. Intravenous (IV) therapy is an important part of clinical care. -an infiltration. ANS: The nurse is caring for a client who is receiving peritoneal dialysis (PD). Study with Quizlet and memorize flashcards containing terms like A nurse is assigned to care for a client with chronic renal failure who is undergoing hemodialysis through an internal arteriovenous (AV) fistula in the right arm. Always secure a peripheral IV catheter with tape or a stabilization device to avoid accidental dislodgement. The nurse is assessing the client. ) Right class Right dose Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is receiving continuous NG tube feedings. Note that the lower the gauge size, the wider the diameter of the catheter, with 14-gauge catheters allowing for the greatest flow rate. A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the volume of intake matches the output. On assessment, the nurse notes that the client's wound has eviscerated. Based on these assessment findings, what will the nurse do next? Remove the peripheral intravenous catheter. Insert a second using a 22 gauge IV catheter, C. History and Physical Three days ago:Current diagnoses- type 2 diabetes mellitusPast medical history- left below the knee amputation 5 years ago. Which intervention would be the highest priority to reduce the risk of aspiration for this patient? Omitted A. Prime the Y-line tubing with dextrose 5% in water B. Change the tube infusion tubing Flush the IV catheter Remove the IV catheter Apply a cool compress to the site. A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Positioning the client on his side c. , Which guideline is appropriate for a nurse to implement while helping family members A nurse is caring for a client who has a peripheral IV inserted for fluid replacement. Which complication of IV therapy should the nurse suspect? The nurse is caring for a client who has been NPO since admission two days ago and was admitted with vomiting as a primary symptom. Which of the following findings should the nurse identify as infiltration of the IV infusion site?, A nurse is preparing to insert an indwelling urinary catheter for a male client. Place the IV and start intravenous fluids promptly; then request the laboratory obtain the blood specimen. The nurse checks the IV site and determines that the client has developed phlebitis. Wean the client from the TPN solution when oral intake is 40% of caloric requirements. Administer indomethacin³ B. Explanation: The sign that indicates infiltration when a client is receiving fluid through a peripheral IV catheter is skin blanching. Administer prescribed medications through a secondary port on the TPN IV tubing. Which of the following actions should the nurse take?, A nurse is assessing a client who is receiving told her parenteral nutrition (TPN). Apply heat to the client's left hand. Which of the following assessment findings should the nurse identify as an indication of a hypersensitivity reaction to the phenytoin? a) enlargement of the cervical lymph nodes b) diarrhea c) ringing in The nurse should understand that who is responsible for inserting the catheter into the client's epidural space? A) Anesthesiologist B (PCTS). A PICC line is a long catheter inserted through the veins of the antecubital fossa. It can be used to restore fluids, administer blood products or medications, or serve as an alternate route for nutrition when the gastrointestinal tract is not functioning adequately. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client in the emergency department (ED). 4. Which technique would be most appropriate for the nurse to administer the secondary infusion by gravity?, A nurse who Study with Quizlet and memorize flashcards containing terms like A nurse is assessing an older adult client who is receiving IV therapy. , A nurse has just initiated a new Study with Quizlet and memorize flashcards containing terms like The nurse is assisting with caring for a client who will receive a unit of blood. A nurse is checking the insertion site of a peripheral IV catheter. Which of the following actions by the nurse is appropriate?, A nurse is monitoring a client who is receiving an IV medication. Which of the following IV fluids does the nurse anticipate a prescription for and why? 10% dextrose in water because it pulls fluid from the cells and increases vascular volume 0. What nursing diagnosis is most appropriate for this client? A nurse is caring for a client who received IV calcium. Which action is most appropriate?, Which hospitalized clients are good candidates for capping of an existing intravenous line for intermittent use? Select all that apply. -Place the client in Sims' position. ) A. Hyperglycemia b. Avoid sites that are areas of flexion. Why would the physician designate the slower infusion rate for this client? The client may have cardiac or renal disorders. Flashcards; Learn; Test; Match; Q-Chat; A client is receiving intravenous (IV) fluids through a minidrop or microdrop. Which of the following actions should the nurse take? (Select all that apply. Chill the formula prior to administration C. When caring for the client's IV site, the nurse should: A. The nurse notes swelling and coolness at the site along with an absent blood return. Exhibit 1 Nurses' Notes Day 1: Lactated Ringer's at 100 mL/hr infusing into a 20-gauge IV catheter in left hand. bounding Study with Quizlet and memorize flashcards containing terms like A nurse is assisting in the care of a client who has heart failure and a prescription to receive a unit of packed red blood cells. TPN The nurse is caring for a client who has a peripheral IV in place for fluid replacement. • Discontinue short-term peripheral IV Because a patient’s fluid and electrolyte statuses are constantly changing when receiving IV fluids, it is important for the nurse to monitor for signs of fluid or electrolyte imbalances and appropriately notify the health care provider of any concerns. 0530: indicated - Administer a 0. 9% sodium chloride 200 mL IV bolus: indicated - Place the client in Trendelenburg position: indicated. 9% sodium chloride to a client who is postoperative and has fluid volume deficit. hypoactive bowel sounds C. Provide the client with a salt substitute c. The nurse should stop the insertion procedure when there is a break in technique. ask about increased thirst B. [6] Catheter sizes are color coded to allow for easy identification Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is receiving an IV fluid replacement. There are two types of fluids that are used for intravenous drips; crystalloids and colloids. Insert an indwelling urinary catheter. TPN therapy is indicated for a client with a weight loss of 10% of the ideal weight, an inability to take oral food or fluids within 7 days post-surgery, and hypercatabolic situations such as major infection with fever. since admission with Lactated Ringers (LR) as the intravenous solution. After the nurse inserts the IV catheter, the client reports pain in the insertion area. d. The client reports dizziness and tight feeling in his When administering IV fluids to a patient, the nurse must continually monitor the patient’s fluid and electrolyte status to evaluate the effectiveness of the infusion and to avoid potential complications of fluid The nurse is caring for a patient who is receiving IV fluids at a rate of 150 mL per hour. Change the feeding bag every 48 hours B. The client is dehydrated and requires a smaller gauge catheter than the 20 gauge being replaced. unstable approach to client care, the nurse should assess this client first. Leave the roller clamp slightly open. Flush tubing with 20 mL water after feeding is completed. A peripheral catheter can be used for the administration of peripheral parenteral nutrition for 5 to 7 days. The nurse should document this drainage as which of the following? a. Which action should the nurse take next? a. 6. The nurse removes the administration set from the package and applies the label to the tubing. Which of the following findings should the nurse identify as INFILTRATION of the IV infusion site, A nurse is proving teaching to a group of unit nurse about wound healing by secondary intention. 9% sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips. Hypophosphatemia, A nurse is assessing a client Study with Quizlet and memorize flashcards containing terms like The nurse is caring for several clients receiving IV therapy. Obtain a capillary blood glucose four times daily. measure urine output C. Carefully reinsert Catheter Size and Type Selection. This intervention helps prevent catheter-related bloodstream infections and provides high-quality care to Study with Quizlet and memorize flashcards containing terms like The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Compare and contrast signs and symptoms along with nursing interventions for infiltration and phlebitis at an IV insertion site. The catheter passes through the wall of Study with Quizlet and memorize flashcards containing terms like A client is to receive a 1,000 mL bag of 5% dextrose in lactated ringer's over 8hr. Place Study with Quizlet and memorize flashcards containing terms like 1. What immediate action should the nurse Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client at home who is receiving parenteral nutrition. For which of the following complications should the nurse monitor? a) The need for multiple IV sticks b) Infection at the access site c) Dehydration d) Infiltration, A charge nurse is observing a newly The nurse is supervising a new graduate nurse who is caring for a client receiving total parenteral nutrition for the last two weeks. Administer a dose of an antiemetic prescribed PRN to Study with Quizlet and memorize flashcards containing terms like 1. Which of the following findings should the nurse identify is infiltration of the IV infusion site?, A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a patient receiving antineoplastic medications intravenously. The client reports dizziness and a feeling of chest Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who requires a replacement peripheral IV. The IV fluids are infusing at 120 mL/hr. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has developed fluid overload following continuous IV infusion of 200 mL/hr. This intervention helps prevent catheter-related bloodstream infections and provides high-quality care to Study with Quizlet and memorize flashcards containing terms like A nurse is administering 1 L of 0. When preparing to administer this medication by intermittent IV bolus, which of the following actions should the nurse take Study with Quizlet and memorize flashcards containing terms like A nurse finds a patient's IV insertion site red, warm, and slightly edematous. When preparing to administer this medication by intermittent IV bolus, which of the following actions should the nurse take A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment? A. Client's name and hospital number Client's response to the insertion Date and time inserted Type and size of device Type of Study with Quizlet and memorize flashcards containing terms like 1) Increased heart rate 2) Increase blood pressure 3) Increased respiratory rate 4) Increased hematocrit 5) Increased temperature A nurse is assessing a client who has fluid overload. Sanguineous d. What action will the nurse take next? a. The nurse notices that the client has a full, bounding pulse, dyspnea, and jugular venous distention. Which of the following actions should the nurse take? A nurse is caring for a client who received IV calcium. Which of the following assessments will the nurse prioritize as a result of this finding? A. Replace the client's transparent IV dressing every 24 hours Study with Quizlet and memorize flashcards containing terms like Total parenteral nutrition (TPN) is prescribed for a client who has recently had a small and large bowel resection and who is currently not taking anything by mouth. Vein to be used for therapy d. Adding potassium and antibiotic to the dialysate bags b. Explain the principles of peripheral intravenous site selection and contraindications. D) Place a piece of paper tape over the insertion site. Hyponatremia d. Delay both the IV start and blood draw until the A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. If they go through air or fluid, the tones are louder. The nurse is caring for a client receiving mechanical ventilation. oslxvpdeoanmhrnjuqgyyxrklnpaqqeeqmltiiobuunkmreunsi
