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Skills in Clinical Nursing 8th Edition Berman Snyder Test Bank

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Skills in Clinical Nursing 8th Edition Berman Snyder Test Bank

ISBN-13: 978-0133997439

ISBN-10: 013399743X

 

 

 

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Skills in Clinical Nursing 8th Edition Berman Snyder Test Bank

ISBN-13: 978-0133997439

ISBN-10: 013399743X

 

 

 

 

 

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Free Nursing Test Questions:

Berman/Snyder, Test Bank for Skills in Clinical Nursing 8th Edition
Chapter 18

Question 1

Type: MCSA

The nurse is initiating IV therapy for an adult client who requires IV fluid infusion for 2–3 days and might require blood administration. Which would the nurse choose as the best option for IV catheterization?

  1. Butterfly
  2. Huber needle
  3. Angiocatheter
  4. Implantable venous access device

Correct Answer: 3

Rationale 1: An angiocatheter would be the best choice because the needle is removed and only the catheter remains in placeRemember, it is more likely to last for 2 days without infiltrating. A butterfly can be used, if necessary, for IV catheterization, but is best when used for short-term IV infusion, as the needle remains in place within the vein, and is more likely to infiltrate sooner than is an angiocatheter. A Huber needle is used to access an implantable venous access device, and would not be used for short-term use of a few days. Implantable venous access devices are used when IV fluid needs are anticipated for several months.

Rationale 2: An angiocatheter would be the best choice because the needle is removed and only the catheter remains in placeRemember, it is more likely to last for 2 days without infiltrating. A butterfly can be used, if necessary, for IV catheterization, but is best when used for short-term IV infusion, as the needle remains in place within the vein, and is more likely to infiltrate sooner than is an angiocatheter. A Huber needle is used to access an implantable venous access device, and would not be used for short-term use of a few days. Implantable venous access devices are used when IV fluid needs are anticipated for several months.

Rationale 3: An angiocatheter would be the best choice because the needle is removed and only the catheter remains in placeRemember, it is more likely to last for 2 days without infiltrating. A butterfly can be used, if necessary, for IV catheterization, but is best when used for short-term IV infusion, as the needle remains in place within the vein, and is more likely to infiltrate sooner than is an angiocatheter. A Huber needle is used to access an implantable venous access device, and would not be used for short-term use of a few days. Implantable venous access devices are used when IV fluid needs are anticipated for several months.

Rationale 4: An angiocatheter would be the best choice because the needle is removed and only the catheter remains in placeRemember, it is more likely to last for 2 days without infiltrating. A butterfly can be used, if necessary, for IV catheterization, but is best when used for short-term IV infusion, as the needle remains in place within the vein, and is more likely to infiltrate sooner than is an angiocatheter. A Huber needle is used to access an implantable venous access device, and would not be used for short-term use of a few days. Implantable venous access devices are used when IV fluid needs are anticipated for several months.

Global Rationale: An angiocatheter would be the best choice because the needle is removed and only the catheter remains in placeRemember, it is more likely to last for 2 days without infiltrating. A butterfly can be used, if necessary, for IV catheterization, but is best when used for short-term IV infusion, as the needle remains in place within the vein, and is more likely to infiltrate sooner than is an angiocatheter. A Huber needle is used to access an implantable venous access device, and would not be used for short-term use of a few days. Implantable venous access devices are used when IV fluid needs are anticipated for several months.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacologic and Parenteral Therapies

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes

AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research

NLN Competencies: Knowledge and Science: Value evidence-based approaches to yield best practices for nursing

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Define the key terms used in the skills of intravenous therapy.

Page Number: p. 445

 

Question 2

Type: MCSA

The nurse is caring for a client with an IV line continuously infusing solution containing dextrose and water. The client complains of a burning pain along the course of the vein, and the nurse assesses the site to find redness, warmth, and mild swelling at the site. Based on these assessment findings, which term will the nurse use when documenting these findings?

  1. Phlebitis at the IV insertion site
  2. IV infiltrate
  3. Extravasated vesicant drug
  4. Extravasation

Correct Answer: 1

Rationale 1: Redness, warmth, edema, and pain that runs along the course of the vein characterize phlebitis. Dextrose and water are not vesicants, and do not require immediate intervention. An infiltrate is defined as fluid entering the tissues, resulting in swelling, coolness, pallor, and discomfort at the site. This client’s site is red and warm, not cool and paleRemember, it is not an infiltrate. Extravasation includes a vesicant drug (one that causes blistering when in the tissues but not in the vascular system)Remember, this is not an extravasation.

Rationale 2: Redness, warmth, edema, and pain that runs along the course of the vein characterize phlebitis. Dextrose and water are not vesicants, and do not require immediate intervention. An infiltrate is defined as fluid entering the tissues, resulting in swelling, coolness, pallor, and discomfort at the site. This client’s site is red and warm, not cool and paleRemember, it is not an infiltrate. Extravasation includes a vesicant drug (one that causes blistering when in the tissues but not in the vascular system)Remember, this is not an extravasation.

Rationale 3: Redness, warmth, edema, and pain that runs along the course of the vein characterize phlebitis. Dextrose and water are not vesicants, and do not require immediate intervention. An infiltrate is defined as fluid entering the tissues, resulting in swelling, coolness, pallor, and discomfort at the site. This client’s site is red and warm, not cool and paleRemember, it is not an infiltrate. Extravasation includes a vesicant drug (one that causes blistering when in the tissues but not in the vascular system)Remember, this is not an extravasation.

Rationale 4: Redness, warmth, edema, and pain that runs along the course of the vein characterize phlebitis. Dextrose and water are not vesicants, and do not require immediate intervention. An infiltrate is defined as fluid entering the tissues, resulting in swelling, coolness, pallor, and discomfort at the site. This client’s site is red and warm, not cool and paleRemember, it is not an infiltrate. Extravasation includes a vesicant drug (one that causes blistering when in the tissues but not in the vascular system)Remember, this is not an extravasation.

Global Rationale: Redness, warmth, edema, and pain that runs along the course of the vein characterize phlebitis. Dextrose and water are not vesicants, and do not require immediate intervention. An infiltrate is defined as fluid entering the tissues, resulting in swelling, coolness, pallor, and discomfort at the site. This client’s site is red and warm, not cool and paleRemember, it is not an infiltrate. Extravasation includes a vesicant drug (one that causes blistering when in the tissues but not in the vascular system)Remember, this is not an extravasation.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacologic and Parenteral Therapies

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes

AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research

NLN Competencies: Knowledge and Science: Value evidence-based approaches to yield best practices for nursing

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Define the key terms used in the skills of intravenous therapy.

Page Number: p. 461

 

Question 3

Type: MCSA

The nurse is caring for a client with a medical diagnosis of increased intracranial pressure. Which IV fluid order would the nurse accept without questioning?

  1. Run normal saline at 125 mL/hour.
  2. Run 5% dextrose in water at 80 mL/hour.
  3. Run 5% dextrose in 0.45% NaCl at 75 mL/hour.
  4. Run half-normal saline at 200 mL/hour.

Correct Answer: 3

Rationale 1: Isotonic and hypotonic fluids should not be administered to clients with increased intracranial pressure, because they increase the risk of cerebral edema. D5 in one-half normal saline is hypertonic, and would be an acceptable IV solution for this client. Normal saline and D5W are isotonic solutions, and so would need to be questioned. Half-normal saline is hypotonic, and so would not be advisable for this client.

Rationale 2: Isotonic and hypotonic fluids should not be administered to clients with increased intracranial pressure, because they increase the risk of cerebral edema. D5 in one-half normal saline is hypertonic, and would be an acceptable IV solution for this client. Normal saline and D5W are isotonic solutions, and so would need to be questioned. Half-normal saline is hypotonic, and so would not be advisable for this client.

Rationale 3: Isotonic and hypotonic fluids should not be administered to clients with increased intracranial pressure, because they increase the risk of cerebral edema. D5 in one-half normal saline is hypertonic, and would be an acceptable IV solution for this client. Normal saline and D5W are isotonic solutions, and so would need to be questioned. Half-normal saline is hypotonic, and so would not be advisable for this client.

Rationale 4: Isotonic and hypotonic fluids should not be administered to clients with increased intracranial pressure, because they increase the risk of cerebral edema. D5 in one-half normal saline is hypertonic, and would be an acceptable IV solution for this client. Normal saline and D5W are isotonic solutions, and so would need to be questioned. Half-normal saline is hypotonic, and so would not be advisable for this client.

Global Rationale: Isotonic and hypotonic fluids should not be administered to clients with increased intracranial pressure, because they increase the risk of cerebral edema. D5 in one-half normal saline is hypertonic, and would be an acceptable IV solution for this client. Normal saline and D5W are isotonic solutions, and so would need to be questioned. Half-normal saline is hypotonic, and so would not be advisable for this client.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacologic and Parenteral Therapies

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes

AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings

NLN Competencies: Quality and Safety: Current best practices

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Identify common types of intravenous infusion equipment.

Page Number: pp. 443-444

 

Question 4

Type: MCSA

The nurse working in the emergency department is caring for a client who experienced deep-thickness burns over 40% of the body and is in shock. Which prescription does the nurse anticipate for this client?

  1. Electrolyte solutions
  2. Volume expanders
  3. Nutrient solutions
  4. Total parenteral nutrition

Correct Answer: 2

Rationale 1: Initially, the client who is in shock will require volume expanders. Once vital signs are stabilized, the primary care provider may order electrolyte solutions. Long term, this client might require total parenteral nutrition if he is unable to maintain adequate calorie intake orally, but nutritional solutions would not be a priority concern this early in the client’s course of treatment.

Rationale 2: Initially, the client who is in shock will require volume expanders. Once vital signs are stabilized, the primary care provider may order electrolyte solutions. Long term, this client might require total parenteral nutrition if he is unable to maintain adequate calorie intake orally, but nutritional solutions would not be a priority concern this early in the client’s course of treatment.

Rationale 3: Initially, the client who is in shock will require volume expanders. Once vital signs are stabilized, the primary care provider may order electrolyte solutions. Long term, this client might require total parenteral nutrition if he is unable to maintain adequate calorie intake orally, but nutritional solutions would not be a priority concern this early in the client’s course of treatment.

Rationale 4: Initially, the client who is in shock will require volume expanders. Once vital signs are stabilized, the primary care provider may order electrolyte solutions. Long term, this client might require total parenteral nutrition if he is unable to maintain adequate calorie intake orally, but nutritional solutions would not be a priority concern this early in the client’s course of treatment.

Global Rationale: Initially, the client who is in shock will require volume expanders. Once vital signs are stabilized, the primary care provider may order electrolyte solutions. Long term, this client might require total parenteral nutrition if he is unable to maintain adequate calorie intake orally, but nutritional solutions would not be a priority concern this early in the client’s course of treatment.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacologic and Parenteral Therapies

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes

AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings

NLN Competencies: Quality and Safety: Current best practices

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Identify common types of intravenous infusion equipment.

Page Number: p. 444

 

 

Question 5

Type: MCMA

Which clients may benefit from central venous IV access?

Standard Text: Select all that apply.

  1. The client requiring long-term IV therapy
  2. The client receiving caustic IV therapy
  3. The client requiring numerous IV infusions that are not compatible and cannot be infused together
  4. The unstable client requiring reliable IV access for administration of medications required immediately
  5. The client who is afraid of needles and does not want a catheter in the peripheral extremity

Correct Answer: 1,2,3,4

Rationale 1: Central venous access can be very useful for clients requiring long-term IV therapy because the catheter can remain in place for extended periods, and IV sites do not have to be changed every few days. Caustic medications are less likely to cause phlebitis when administered into the large central veins as opposed to the smaller peripheral veins. In the critical care areas where clients may receive numerous continuous IV medication drips that might not all be compatible infusing through the same site, a multiple-port central venous access device can provide the best option. Clients who are unstable and require rapid administration of medications require reliable IV access that might not be available with peripheral IV lines, and central venous access may be the best option. Because of the potential complications from central venous access, it would not be an option considered because of client preference if short-term IV therapy is required.

Rationale 2: Central venous access can be very useful for clients requiring long-term IV therapy because the catheter can remain in place for extended periods, and IV sites do not have to be changed every few days. Caustic medications are less likely to cause phlebitis when administered into the large central veins as opposed to the smaller peripheral veins. In the critical care areas where clients may receive numerous continuous IV medication drips that might not all be compatible infusing through the same site, a multiple-port central venous access device can provide the best option. Clients who are unstable and require rapid administration of medications require reliable IV access that might not be available with peripheral IV lines, and central venous access may be the best option. Because of the potential complications from central venous access, it would not be an option considered because of client preference if short-term IV therapy is required.

Rationale 3: Central venous access can be very useful for clients requiring long-term IV therapy because the catheter can remain in place for extended periods, and IV sites do not have to be changed every few days. Caustic medications are less likely to cause phlebitis when administered into the large central veins as opposed to the smaller peripheral veins. In the critical care areas where clients may receive numerous continuous IV medication drips that might not all be compatible infusing through the same site, a multiple-port central venous access device can provide the best option. Clients who are unstable and require rapid administration of medications require reliable IV access that might not be available with peripheral IV lines, and central venous access may be the best option. Because of the potential complications from central venous access, it would not be an option considered because of client preference if short-term IV therapy is required.

Rationale 4: Central venous access can be very useful for clients requiring long-term IV therapy because the catheter can remain in place for extended periods, and IV sites do not have to be changed every few days. Caustic medications are less likely to cause phlebitis when administered into the large central veins as opposed to the smaller peripheral veins. In the critical care areas where clients may receive numerous continuous IV medication drips that might not all be compatible, infusing through the same site, a multiple-port central venous access device can provide the best option. Clients who are unstable and require rapid administration of medications require reliable IV access that might not be available with peripheral IV lines, and central venous access may be the best option. Because of the potential complications from central venous access, it would not be an option considered because of client preference if short-term IV therapy is required.

Rationale 5: Central venous access can be very useful for clients requiring long-term IV therapy because the catheter can remain in place for extended periods, and IV sites do not have to be changed every few days. Caustic medications are less likely to cause phlebitis when administered into the large central veins as opposed to the smaller peripheral veins. In the critical care areas where clients may receive numerous continuous IV medication drips that might not all be compatible infusing through the same site, a multiple-port central venous access device can provide the best option. Clients who are unstable and require rapid administration of medications require reliable IV access that might not be available with peripheral IV lines, and central venous access may be the best option. Because of the potential complications from central venous access, it would not be an option considered because of client preference if short-term IV therapy is required.

Global Rationale: Central venous access can be very useful for clients requiring long-term IV therapy because the catheter can remain in place for extended periods, and IV sites do not have to be changed every few days. Caustic medications are less likely to cause phlebitis when administered into the large central veins as opposed to the smaller peripheral veins. In the critical care areas where clients may receive numerous continuous IV medication drips that might not all be compatible infusing through the same site, a multiple-port central venous access device can provide the best option. Clients who are unstable and require rapid administration of medications require reliable IV access that might not be available with peripheral IV lines, and central venous access may be the best option. Because of the potential complications from central venous access, it would not be an option considered because of client preference if short-term IV therapy is required.

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes

AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings

NLN Competencies: Knowledge and Science: Value evidence-based approaches to yield best practices for nursing

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Identify indications and contraindications for intravenous therapy and central venous lines.

Page Number: pp. 471-476

 

Question 6

Type: MCSA

Which aspect of intravenous therapy could the nurse safely delegate to the unlicensed assistive personnel (UAP)?

  1. Watching the IV insertion site of the client who complained of pain at the site
  2. Changing the IV site dressing on the client’s left hand
  3. Reporting client’s complaints of pain or leakage from the IV site when bathing the client
  4. Replacing client’s IV solution when bag runs dry if it is only D5W, without medications added

Correct Answer: 3

Rationale 1: The UAP can safely be taught to report complaints of pain or leakage from an IV site if it is noted during routine care, but the UAP is not responsible for assessing the site, because the nurse is responsible for all assessments. The IV dressing should be changed using sterile technique, and should not be delegated to the UAP. Whether medications are added to the IV fluid or not, only the nurse can change the bag, because sterile technique is required, and even a plain solution is considered a medication.

Rationale 2: The UAP can safely be taught to report complaints of pain or leakage from an IV site if it is noted during routine care, but the UAP is not responsible for assessing the site, because the nurse is responsible for all assessments. The IV dressing should be changed using sterile technique, and should not be delegated to the UAP. Whether medications are added to the IV fluid or not, only the nurse can change the bag, because sterile technique is required, and even a plain solution is considered a medication.

Rationale 3: The UAP can safely be taught to report complaints of pain or leakage from an IV site if it is noted during routine care, but the UAP is not responsible for assessing the site, because the nurse is responsible for all assessments. The IV dressing should be changed using sterile technique, and should not be delegated to the UAP. Whether medications are added to the IV fluid or not, only the nurse can change the bag, because sterile technique is required, and even a plain solution is considered a medication.

Rationale 4: The UAP can safely be taught to report complaints of pain or leakage from an IV site if it is noted during routine care, but the UAP is not responsible for assessing the site, because the nurse is responsible for all assessments. The IV dressing should be changed using sterile technique, and should not be delegated to the UAP. Whether medications are added to the IV fluid or not, only the nurse can change the bag, because sterile technique is required, and even a plain solution is considered a medication.

Global Rationale: The UAP can safely be taught to report complaints of pain or leakage from an IV site if it is noted during routine care, but the UAP is not responsible for assessing the site, because the nurse is responsible for all assessments. The IV dressing should be changed using sterile technique, and should not be delegated to the UAP. Whether medications are added to the IV fluid or not, only the nurse can change the bag, because sterile technique is required, and even a plain solution is considered a medication.

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members

AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team

NLN Competencies: Teamwork: Manage delegation effectively.

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Recognize when it is appropriate to delegate aspects of intravenous therapy to unlicensed assistive personnel.

Page Number: p. 459

 

Question 7

Type: MCMA

The nurse is performing venipuncture to initiate IV therapy. The venipuncture site is chosen based on which indicators?

Standard Text: Select all that apply.

  1. Using the client’s dominant arm, whenever possible
  2. Choosing a relatively straight vein
  3. Avoiding sclerotic veins
  4. Looking for a site sufficiently distal to joints
  5. Choosing a vein that is visible in addition to palpable

Correct Answer: 2,3,4

Rationale 1: The nurse should choose a vein that is straight and not sclerotic. Sclerotic veins make it difficult to obtain and maintain IV therapy. Straight veins provide space for the catheter to be inserted easily. The site should be sufficiently distal to the wrist or elbow joint to avoid bending or kinking of the IV catheter. It is best, when possible, to use the client’s nondominant arm, because movement might be somewhat limitedRemember, the client should be allowed to use the dominant arm. Some clients, especially dark-skinned people, might not have easily visible veinsRemember, the veins should be palpable even if not visible.

Rationale 2: The nurse should choose a vein that is straight and not sclerotic. Sclerotic veins make it difficult to obtain and maintain IV therapy. Straight veins provide space for the catheter to be inserted easily. The site should be sufficiently distal to the wrist or elbow joint to avoid bending or kinking of the IV catheter. It is best, when possible, to use the client’s nondominant arm, because movement might be somewhat limitedRemember, the client should be allowed to use the dominant arm. Some clients, especially dark-skinned people, might not have easily visible veinsRemember, the veins should be palpable even if not visible.

Rationale 3: The nurse should choose a vein that is straight and not sclerotic. Sclerotic veins make it difficult to obtain and maintain IV therapy. Straight veins provide space for the catheter to be inserted easily. The site should be sufficiently distal to the wrist or elbow joint to avoid bending or kinking of the IV catheter. It is best, when possible, to use the client’s nondominant arm, because movement might be somewhat limitedRemember, the client should be allowed to use the dominant arm. Some clients, especially dark-skinned people, might not have easily visible veinsRemember, the veins should be palpable even if not visible.

Rationale 4: The nurse should choose a vein that is straight and not sclerotic. Sclerotic veins make it difficult to obtain and maintain IV therapy. Straight veins provide space for the catheter to be inserted easily. The site should be sufficiently distal to the wrist or elbow joint to avoid bending or kinking of the IV catheter. It is best, when possible, to use the client’s nondominant arm, because movement might be somewhat limitedRemember, the client should be allowed to use the dominant arm. Some clients, especially dark-skinned people, might not have easily visible veinsRemember, the veins should be palpable even if not visible.

Rationale 5: The nurse should choose a vein that is straight and not sclerotic. Sclerotic veins make it difficult to obtain and maintain IV therapy. Straight veins provide space for the catheter to be inserted easily. The site should be sufficiently distal to the wrist or elbow joint to avoid bending or kinking of the IV catheter. It is best, when possible, to use the client’s nondominant arm, because movement might be somewhat limitedRemember, the client should be allowed to use the dominant arm. Some clients, especially dark-skinned people, might not have easily visible veinsRemember, the veins should be palpable even if not visible.

Global Rationale: The nurse should choose a vein that is straight and not sclerotic. Sclerotic veins make it difficult to obtain and maintain IV therapy. Straight veins provide space for the catheter to be inserted easily. The site should be sufficiently distal to the wrist or elbow joint to avoid bending or kinking of the IV catheter. It is best, when possible, to use the client’s nondominant arm, because movement might be somewhat limitedRemember, the client should be allowed to use the dominant arm. Some clients, especially dark-skinned people, might not have easily visible veinsRemember, the veins should be palpable even if not visible.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacologic and Parenteral Therapies

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice

AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings

NLN Competencies: Quality and Safety: Current best practices

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Verbalize the steps used in:
a. Performing venipuncture.
b. Starting an intravenous infusion.
c. Using an electronic infusion device.
d. Maintaining infusions.
e. Maintaining intermittent infusion devices.
f. Discontinuing infusion devices.
g. Administering blood transfusions.
h. Managing central venous access devices.
i. Performing central venous access device dressing changes.
j. Working with implanted vascular access devices.

Page Number: p. 453

 

Question 8

Type: MCSA

The nurse initiating IV therapy is preparing a solution to which potassium chloride has been added. After adding the medication, which action by the nurse regarding the IV label is appropriate?

  1. Writing the time the IV solution needs to be changed
  2. Placing it upside-down on the container
  3. Putting it around the IV tubing
  4. Documenting the size of the angiocatheter inserted to obtain IV access

Correct Answer: 2

Rationale 1: The label should be applied upside-down so it can be read when the IV bag is hung upside-down from the IV pole. The time the solution needs to be changed would be indicated with a time label to indicate when the solution was hung. A label indicating when the IV tubing needs to be changed would be applied around the tubing, not the medication label. The size of the angiocatheter should be documented, but it would not be written on the medication label.

Rationale 2: The label should be applied upside-down so it can be read when the IV bag is hung upside-down from the IV pole. The time the solution needs to be changed would be indicated with a time label to indicate when the solution was hung. A label indicating when the IV tubing needs to be changed would be applied around the tubing, not the medication label. The size of the angiocatheter should be documented, but it would not be written on the medication label.

Rationale 3: The label should be applied upside-down so it can be read when the IV bag is hung upside-down from the IV pole. The time the solution needs to be changed would be indicated with a time label to indicate when the solution was hung. A label indicating when the IV tubing needs to be changed would be applied around the tubing, not the medication label. The size of the angiocatheter should be documented, but it would not be written on the medication label.

Rationale 4: The label should be applied upside-down so it can be read when the IV bag is hung upside-down from the IV pole. The time the solution needs to be changed would be indicated with a time label to indicate when the solution was hung. A label indicating when the IV tubing needs to be changed would be applied around the tubing, not the medication label. The size of the angiocatheter should be documented, but it would not be written on the medication label.

Global Rationale: The label should be applied upside-down so it can be read when the IV bag is hung upside-down from the IV pole. The time the solution needs to be changed would be indicated with a time label to indicate when the solution was hung. A label indicating when the IV tubing needs to be changed would be applied around the tubing, not the medication label. The size of the angiocatheter should be documented, but it would not be written on the medication label.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacologic and Parenteral Therapies

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice

AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings

NLN Competencies: Quality and Safety: Current best practices

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Verbalize the steps used in:
a. Performing venipuncture.
b. Starting an intravenous infusion.
c. Using an electronic infusion device.
d. Maintaining infusions.
e. Maintaining intermittent infusion devices.
f. Discontinuing infusion devices.
g. Administering blood transfusions.
h. Managing central venous access devices.
i. Performing central venous access device dressing changes.
j. Working with implanted vascular access devices.

Page Number: pp. 454-455

 

Question 9

Type: MCSA

The nurse is setting up an IV infusion on an electronic infusion pump. After leaving the room, the pump alarms and reads high pressure. Which is the priority action by the nurse?

  1. Resetting the pump to resume infusion
  2. Discontinuing the client’s IV access and restarting in a different area
  3. Assessing the client’s IV site and the tubing for kinks or closed roller clamps
  4. Asking the client if the pump has been tampered with in any way

Correct Answer: 3

Rationale 1: The nurse should assess the IV site because an infiltrated IV, or a site that is proximal to a joint, can impede infusion. If the IV site appears to be within normal limits, the tubing should be checked for any kinks, closed roller clamps, or any other impediment to infusion. Resetting the pump without performing a thorough assessment could increase the tissue damage if the site is infiltrated. The IV site should not be discontinued if it is intactRemember, it should be assessed before considering moving the site. Accusing the client of tampering with the pump would not be justified.

Rationale 2: The nurse should assess the IV site because an infiltrated IV, or a site that is proximal to a joint, can impede infusion. If the IV site appears to be within normal limits, the tubing should be checked for any kinks, closed roller clamps, or any other impediment to infusion. Resetting the pump without performing a thorough assessment could increase the tissue damage if the site is infiltrated. The IV site should not be discontinued if it is intactRemember, it should be assessed before considering moving the site. Accusing the client of tampering with the pump would not be justified.

Rationale 3: The nurse should assess the IV site because an infiltrated IV, or a site that is proximal to a joint, can impede infusion. If the IV site appears to be within normal limits, the tubing should be checked for any kinks, closed roller clamps, or any other impediment to infusion. Resetting the pump without performing a thorough assessment could increase the tissue damage if the site is infiltrated. The IV site should not be discontinued if it is intactRemember, it should be assessed before considering moving the site. Accusing the client of tampering with the pump would not be justified.

Rationale 4: The nurse should assess the IV site because an infiltrated IV, or a site that is proximal to a joint, can impede infusion. If the IV site appears to be within normal limits, the tubing should be checked for any kinks, closed roller clamps, or any other impediment to infusion. Resetting the pump without performing a thorough assessment could increase the tissue damage if the site is infiltrated. The IV site should not be discontinued if it is intactRemember, it should be assessed before considering moving the site. Accusing the client of tampering with the pump would not be justified.

Global Rationale: The nurse should assess the IV site because an infiltrated IV, or a site that is proximal to a joint, can impede infusion. If the IV site appears to be within normal limits, the tubing should be checked for any kinks, closed roller clamps, or any other impediment to infusion. Resetting the pump without performing a thorough assessment could increase the tissue damage if the site is infiltrated. The IV site should not be discontinued if it is intactRemember, it should be assessed before considering moving the site. Accusing the client of tampering with the pump would not be justified.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacologic and Parenteral Therapies

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice

AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings

NLN Competencies: Quality and Safety: Current best practices

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Verbalize the steps used in:
a. Performing venipuncture.
b. Starting an intravenous infusion.
c. Using an electronic infusion device.
d. Maintaining infusions.
e. Maintaining intermittent infusion devices.
f. Discontinuing infusion devices.
g. Administering blood transfusions.
h. Managing central venous access devices.
i. Performing central venous access device dressing changes.
j. Working with implanted vascular access devices.

Page Number: pp. 458-459

 

Question 10

Type: MCMA

The nurse discontinues the client’s IV prior to discharge. After removing the catheter, which actions by the nurse are appropriate?

Standard Text: Select all that apply.

  1. Applying pressure to the insertion site until bleeding stops
  2. Examining the removed catheter to ensure that it is intact
  3. Teaching the client to inform the nurse if the site begins to bleed at any time
  4. Holding the client’s extremity below the level of the heart if bleeding persists
  5. Covering the venipuncture site with a sterile dressing

Correct Answer: 1,2,3,5

Rationale 1: All the actions by the nurse are appropriate except holding the client’s extremity below the level of the heart if bleeding persists. The client’s extremity should be held above the level of the heart if bleeding persists.

Rationale 2: All the actions by the nurse are appropriate except holding the client’s extremity below the level of the heart if bleeding persists. The client’s extremity should be held above the level of the heart if bleeding persists.

Rationale 3: All the actions by the nurse are appropriate except holding the client’s extremity below the level of the heart if bleeding persists. The client’s extremity should be held above the level of the heart if bleeding persists.

Rationale 4: All the actions by the nurse are appropriate except holding the client’s extremity below the level of the heart if bleeding persists. The client’s extremity should be held above the level of the heart if bleeding persists.

Rationale 5: All the actions by the nurse are appropriate except holding the client’s extremity below the level of the heart if bleeding persists. The client’s extremity should be held above the level of the heart if bleeding persists.

Global Rationale: All the actions by the nurse are appropriate except holding the client’s extremity below the level of the heart if bleeding persists. The client’s extremity should be held above the level of the heart if bleeding persists.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacologic and Parenteral Therapies

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice

AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings

NLN Competencies: Quality and Safety: Current best practices

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Verbalize the steps used in:
a. Performing venipuncture.
b. Starting an intravenous infusion.
c. Using an electronic infusion device.
d. Maintaining infusions.
e. Maintaining intermittent infusion devices.
f. Discontinuing infusion devices.
g. Administering blood transfusions.
h. Managing central venous access devices.
i. Performing central venous access device dressing changes.
j. Working with implanted vascular access devices.

Page Number: p. 464-465

 

Question 11

Type: MCSA

The nurse begins a blood transfusion, and comes back in 15 minutes to assess the client. The client complains of suddenly feeling cold and is shivering. The client’s blood pressure has decreased since the last assessment. Which is the nurse’s priority action?

  1. Notify the health care provider.
  2. Monitor the client’s blood pressure every 5 minutes.
  3. Stop the blood infusion, and run the normal saline on the other side of the Y tubing.
  4. Stop the blood infusion, and remove the tubing from the IV catheter, replacing it with normal saline.

Correct Answer: 4

Rationale 1: The nurse should completely discontinue the blood infusion, disconnecting the tubing from the IV catheter and placing normal saline or the ordered solution infusing prior to beginning the blood infusion with new tubing. Stopping the blood infusion and running saline through the blood tubing will administer the blood found in the tubing, and could make the transfusion reaction worse. Only after the blood infusion is discontinued would the nurse notify the health care provider and monitor the client’s condition.

Rationale 2: The nurse should completely discontinue the blood infusion, disconnecting the tubing from the IV catheter and placing normal saline or the ordered solution infusing prior to beginning the blood infusion with new tubing. Stopping the blood infusion and running saline through the blood tubing will administer the blood found in the tubing, and could make the transfusion reaction worse. Only after the blood infusion is discontinued would the nurse notify the health care provider and monitor the client’s condition.

Rationale 3: The nurse should completely discontinue the blood infusion, disconnecting the tubing from the IV catheter and placing normal saline or the ordered solution infusing prior to beginning the blood infusion with new tubing. Stopping the blood infusion and running saline through the blood tubing will administer the blood found in the tubing, and could make the transfusion reaction worse. Only after the blood infusion is discontinued would the nurse notify the health care provider and monitor the client’s condition.

Rationale 4: The nurse should completely discontinue the blood infusion, disconnecting the tubing from the IV catheter and placing normal saline or the ordered solution infusing prior to beginning the blood infusion with new tubing. Stopping the blood infusion and running saline through the blood tubing will administer the blood found in the tubing, and could make the transfusion reaction worse. Only after the blood infusion is discontinued would the nurse notify the health care provider and monitor the client’s condition.

Global Rationale: The nurse should completely discontinue the blood infusion, disconnecting the tubing from the IV catheter and placing normal saline or the ordered solution infusing prior to beginning the blood infusion with new tubing. Stopping the blood infusion and running saline through the blood tubing will administer the blood found in the tubing, and could make the transfusion reaction worse. Only after the blood infusion is discontinued would the nurse notify the health care provider and monitor the client’s condition.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacologic and Parenteral Therapies

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice

AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings

NLN Competencies: Quality and Safety: Current best practices

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Verbalize the steps used in:
a. Performing venipuncture.
b. Starting an intravenous infusion.
c. Using an electronic infusion device.
d. Maintaining infusions.
e. Maintaining intermittent infusion devices.
f. Discontinuing infusion devices.
g. Administering blood transfusions.
h. Managing central venous access devices.
i. Performing central venous access device dressing changes.
j. Working with implanted vascular access devices.

Page Number: pp. 468-470

 

Question 12

Type: MCSA

The nurse is caring for a client with a central venous catheter used for intermittent medication administration. When flushing the catheter prior to administering the next dose of medication, which initial action by the nurse is the most appropriate?

  1. Aspirating the catheter for blood
  2. Obtaining a 3 mL syringe and filling it with normal saline for flushing the line
  3. Flushing the catheter, using as much force as required in order to clear the line
  4. Positioning the client in reverse Trendelenburg position

Correct Answer: 1

Rationale 1: The catheter should be aspirated for blood prior to flushing the tubing. The tubing would be flushed with a 10 mL syringe or larger because small syringes exert too much pressure, which can damage the catheter. Excessive pressure should not be used when flushing the catheter, because it can dislodge a clot or cause the catheter to rupture. There would be no need to place the client in reverse Trendelenburg position, although a left Trendelenburg position may be used if an air embolism is suspected.

Rationale 2: The catheter should be aspirated for blood prior to flushing the tubing. The tubing would be flushed with a 10 mL syringe or larger because small syringes exert too much pressure, which can damage the catheter. Excessive pressure should not be used when flushing the catheter, because it can dislodge a clot or cause the catheter to rupture. There would be no need to place the client in reverse Trendelenburg position, although a left Trendelenburg position may be used if an air embolism is suspected.

Rationale 3: The catheter should be aspirated for blood prior to flushing the tubing. The tubing would be flushed with a 10 mL syringe or larger because small syringes exert too much pressure, which can damage the catheter. Excessive pressure should not be used when flushing the catheter, because it can dislodge a clot or cause the catheter to rupture. There would be no need to place the client in reverse Trendelenburg position, although a left Trendelenburg position may be used if an air embolism is suspected.

Rationale 4: The catheter should be aspirated for blood prior to flushing the tubing. The tubing would be flushed with a 10 mL syringe or larger because small syringes exert too much pressure, which can damage the catheter. Excessive pressure should not be used when flushing the catheter, because it can dislodge a clot or cause the catheter to rupture. There would be no need to place the client in reverse Trendelenburg position, although a left Trendelenburg position may be used if an air embolism is suspected.

Global Rationale: The catheter should be aspirated for blood prior to flushing the tubing. The tubing would be flushed with a 10 mL syringe or larger because small syringes exert too much pressure, which can damage the catheter. Excessive pressure should not be used when flushing the catheter, because it can dislodge a clot or cause the catheter to rupture. There would be no need to place the client in reverse Trendelenburg position, although a left Trendelenburg position may be used if an air embolism is suspected.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacologic and Parenteral Therapies

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice

AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings

NLN Competencies: Quality and Safety: Current best practices

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Verbalize the steps used in:
a. Performing venipuncture.
b. Starting an intravenous infusion.
c. Using an electronic infusion device.
d. Maintaining infusions.
e. Maintaining intermittent infusion devices.
f. Discontinuing infusion devices.
g. Administering blood transfusions.
h. Managing central venous access devices.
i. Performing central venous access device dressing changes.
j. Working with implanted vascular access devices.

Page Number: pp. 472-473

 

Question 13

Type: MCSA

When removing an old central line dressing, which action by the nurse is the priority?

  1. Pulling the tape off in the direction of the catheter
  2. Inspecting the insertion site for signs of infection
  3. Pressing the catheter into the client’s skin while removing the tape
  4. Applying sterile gloves

Correct Answer: 1

Rationale 1: The tape should be removed in the direction of the catheter to avoid displacing the catheter. The site is inspected after the old dressing is removed, not while removing the dressing. The catheter should be held in the nurse’s hand while the tape is removed, not pressed into the client’s skin. Sterile gloves are not used when removing the old dressing.

Rationale 2: The tape should be removed in the direction of the catheter to avoid displacing the catheter. The site is inspected after the old dressing is removed, not while removing the dressing. The catheter should be held in the nurse’s hand while the tape is removed, not pressed into the client’s skin. Sterile gloves are not used when removing the old dressing.

Rationale 3: The tape should be removed in the direction of the catheter to avoid displacing the catheter. The site is inspected after the old dressing is removed, not while removing the dressing. The catheter should be held in the nurse’s hand while the tape is removed, not pressed into the client’s skin. Sterile gloves are not used when removing the old dressing.

Rationale 4: The tape should be removed in the direction of the catheter to avoid displacing the catheter. The site is inspected after the old dressing is removed, not while removing the dressing. The catheter should be held in the nurse’s hand while the tape is removed, not pressed into the client’s skin. Sterile gloves are not used when removing the old dressing.

Global Rationale: The tape should be removed in the direction of the catheter to avoid displacing the catheter. The site is inspected after the old dressing is removed, not while removing the dressing. The catheter should be held in the nurse’s hand while the tape is removed, not pressed into the client’s skin. Sterile gloves are not used when removing the old dressing.

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice

AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings

NLN Competencies: Quality and Safety: Current best practices

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Verbalize the steps used in:
a. Performing venipuncture.
b. Starting an intravenous infusion.
c. Using an electronic infusion device.
d. Maintaining infusions.
e. Maintaining intermittent infusion devices.
f. Discontinuing infusion devices.
g. Administering blood transfusions.
h. Managing central venous access devices.
i. Performing central venous access device dressing changes.
j. Working with implanted vascular access devices.

Page Number: pp. 475-476

 

Question 14

Type: MCSA

The nurse is caring for a client who is to have a peripherally inserted central catheter (PICC) line inserted tomorrow afternoon. The client’s peripheral access line is infiltrated, and needs to be restarted. Which site would the nurse avoid using?

  1. Median cubital vein
  2. Cephalic vein
  3. Radial vein
  4. Dorsal metacarpal veins

Correct Answer: 1

Rationale 1: The median cubital vein is often used for PICC linesRemember, the nurse should attempt to avoid this site in order to maintain it for the central line. The other sites would be acceptable choices.

Rationale 2: The median cubital vein is often used for PICC linesRemember, the nurse should attempt to avoid this site in order to maintain it for the central line. The other sites would be acceptable choices.

Rationale 3: The median cubital vein is often used for PICC linesRemember, the nurse should attempt to avoid this site in order to maintain it for the central line. The other sites would be acceptable choices.

Rationale 4: The median cubital vein is often used for PICC linesRemember, the nurse should attempt to avoid this site in order to maintain it for the central line. The other sites would be acceptable choices.

Global Rationale: The median cubital vein is often used for PICC linesRemember, the nurse should attempt to avoid this site in order to maintain it for the central line. The other sites would be acceptable choices.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacologic and Parenteral Therapies

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes

AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings

NLN Competencies: Quality and Safety: Current best practices

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Identify potential venipuncture sites.

Page Number: p. 444

 

 

Question 15

Type: FIB

The nurse receives an order to administer 3 liters of IV fluid over the next 24 hours. The infusion device would be set to administer how many mL per hour?
____ mL/hour

Standard Text: Record the answer rounding to the nearest whole number.

Correct Answer: 125

Rationale: The correct answer is obtained by dividing 3,000 mL (total amount of fluid to be administered over the next 24 hours is 3 liters = 3,000 mL) by the number of hours it is to be infused (24). 3,000 divided by 24 = 125 mL/hr.

Global Rationale: The correct answer is obtained by dividing 3,000 mL (total amount of fluid to be administered over the next 24 hours is 3 liters = 3,000 mL) by the number of hours it is to be infused (24). 3,000 divided by 24 = 125 mL/hr.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacologic and Parenteral Therapies

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes

AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe client care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Calculate and regulate intravenous flow rates.

Page Number: p. 456

 

Question 16

Type: MCMA

The nurse caring for a client receiving parenteral nutrition via a central venous catheter determines that the client’s temperature is elevated, white blood cell count is elevated, and the client is lethargic. The nurse suspects the client is septic. Which actions by the nurse are appropriate in this situation?

Standard Text: Select all that apply.

  1. Replacing the parenteral nutrition with a normal saline solution
  2. Changing the IV tubing
  3. Saving the remaining TPN
  4. Recording the lot number of the TPN
  5. Notifying the health care provider.

Correct Answer: 2,3,4,5

Rationale 1: The fluid should be replaced with a 5% or 10% dextrose solution, not normal saline, because the client has adjusted to a high sugar intake via the TPN, and eliminating all sugar infused could result in hypoglycemia. The other actions are correct.

Rationale 2: The fluid should be replaced with a 5% or 10% dextrose solution, not normal saline, because the client has adjusted to a high sugar intake via the TPN, and eliminating all sugar infused could result in hypoglycemia. The other actions are correct.

Rationale 3: The fluid should be replaced with a 5% or 10% dextrose solution, not normal saline, because the client has adjusted to a high sugar intake via the TPN, and eliminating all sugar infused could result in hypoglycemia. The other actions are correct.

Rationale 4: The fluid should be replaced with a 5% or 10% dextrose solution, not normal saline, because the client has adjusted to a high sugar intake via the TPN, and eliminating all sugar infused could result in hypoglycemia. The other actions are correct.

Rationale 5: The fluid should be replaced with a 5% or 10% dextrose solution, not normal saline, because the client has adjusted to a high sugar intake via the TPN, and eliminating all sugar infused could result in hypoglycemia. The other actions are correct.

Global Rationale: The fluid should be replaced with a 5% or 10% dextrose solution, not normal saline, because the client has adjusted to a high sugar intake via the TPN, and eliminating all sugar infused could result in hypoglycemia. The other actions are correct.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacologic and Parenteral Therapies

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice

AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings

NLN Competencies: Quality and Safety: Current best practices

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Identify interventions that prevent complications associated with intravenous therapy and central venous access devices.

Page Number: p. 472

 

Question 17

Type: MCSA

The nurse caring for a client with IV access accidentally infuses an air embolism. Which is the highest-priority action of the nurse?

  1. Notifying the health care provider
  2. Notifying the charge nurse
  3. Assessing the client
  4. Positioning the client in left Trendelenburg and applying oxygen

Correct Answer: 4

Rationale 1: Lowering the head of the bed increases intrathoracic pressure, decreasing the flow of air into the vein during inhalation. A left side-lying position helps prevent air from moving into the pulmonary artery. Oxygen helps to hyperoxygenate the tissues if the air embolism reduces blood flow to the tissues. The other actions, although necessary, take far lower priority.

Rationale 2: Lowering the head of the bed increases intrathoracic pressure, decreasing the flow of air into the vein during inhalation. A left side-lying position helps prevent air from moving into the pulmonary artery. Oxygen helps to hyperoxygenate the tissues if the air embolism reduces blood flow to the tissues. The other actions, although necessary, take far lower priority.

Rationale 3: Lowering the head of the bed increases intrathoracic pressure, decreasing the flow of air into the vein during inhalation. A left side-lying position helps prevent air from moving into the pulmonary artery. Oxygen helps to hyperoxygenate the tissues if the air embolism reduces blood flow to the tissues. The other actions, although necessary, take far lower priority.

Rationale 4: Lowering the head of the bed increases intrathoracic pressure, decreasing the flow of air into the vein during inhalation. A left side-lying position helps prevent air from moving into the pulmonary artery. Oxygen helps to hyperoxygenate the tissues if the air embolism reduces blood flow to the tissues. The other actions, although necessary, take far lower priority.

Global Rationale: Lowering the head of the bed increases intrathoracic pressure, decreasing the flow of air into the vein during inhalation. A left side-lying position helps prevent air from moving into the pulmonary artery. Oxygen helps to hyperoxygenate the tissues if the air embolism reduces blood flow to the tissues. The other actions, although necessary, take far lower priority.

Cognitive Level: Analyzing

Client Need: Physiologic Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice

AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings

NLN Competencies: Quality and Safety: Current best practices

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Identify interventions that prevent complications associated with intravenous therapy and central venous access devices.

Page Number: p. 474

 

Question 18

Type: MCMA

After changing the client’s central line dressing, which items will the nurse include in the documentation of the procedure?

Standard Text: Select all that apply.

  1. Fluid infusing into the catheter
  2. Assessment of the central line insertion site
  3. Type of dressing applied
  4. Aseptic technique under which the dressing was changed
  5. Client complaints or concerns

Correct Answer: 2,3,4,5

Rationale 1: The nurse should document the appearance of the central line insertion site, the type of dressing applied, and the aseptic technique used, such as “sterile technique used to apply Tegaderm dressing.” If the client voices any concerns or complaints, the nurse would record them, along with actions taken to care for the client. The fluid infusing is documented on the IV infusion record, but not in the note regarding dressing change.

Rationale 2: The nurse should document the appearance of the central line insertion site, the type of dressing applied, and the aseptic technique used, such as “sterile technique used to apply Tegaderm dressing.” If the client voices any concerns or complaints, the nurse would record them, along with actions taken to care for the client. The fluid infusing is documented on the IV infusion record, but not in the note regarding dressing change.

Rationale 3: The nurse should document the appearance of the central line insertion site, the type of dressing applied, and the aseptic technique used, such as “sterile technique used to apply Tegaderm dressing.” If the client voices any concerns or complaints, the nurse would record them, along with actions taken to care for the client. The fluid infusing is documented on the IV infusion record, but not in the note regarding dressing change.

Rationale 4: The nurse should document the appearance of the central line insertion site, the type of dressing applied, and the aseptic technique used, such as “sterile technique used to apply Tegaderm dressing.” If the client voices any concerns or complaints, the nurse would record them, along with actions taken to care for the client. The fluid infusing is documented on the IV infusion record, but not in the note regarding dressing change.

Rationale 5: The nurse should document the appearance of the central line insertion site, the type of dressing applied, and the aseptic technique used, such as “sterile technique used to apply Tegaderm dressing.” If the client voices any concerns or complaints, the nurse would record them, along with actions taken to care for the client. The fluid infusing is documented on the IV infusion record, but not in the note regarding dressing change.

Global Rationale: The nurse should document the appearance of the central line insertion site, the type of dressing applied, and the aseptic technique used, such as “sterile technique used to apply Tegaderm dressing.” If the client voices any concerns or complaints, the nurse would record them, along with actions taken to care for the client. The fluid infusing is documented on the IV infusion record, but not in the note regarding dressing change.

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: VI.B.4. Document and plan client care in an electronic health record

AACN Essential Competencies: IV.5. Use standardized terminology in a care environment that reflects nursing’s unique contribution to client outcomes

NLN Competencies: Quality and Safety: Carefully maintain and use electronic and/or written health records

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Demonstrate appropriate documentation and reporting of intravenous therapy.

Page Number: pp. 475-476

 

 

 

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