PRACTICE QUESTIONS
103. A client had a 1000-mL bag of 5% dextrose in 0.9%
sodium chloride hung at 3 PM. The nurse making rounds at
3:45 PM finds that the client is complaining of a pounding headache
and is dyspneic, is experiencing chills, and is apprehensive, with an increased
pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse
should take which action first?
sodium chloride hung at 3 PM. The nurse making rounds at
3:45 PM finds that the client is complaining of a pounding headache
and is dyspneic, is experiencing chills, and is apprehensive, with an increased
pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse
should take which action first?
1. Slow the IV infusion.
2. Sit the client up in bed.
3. Remove the IV catheter.
4. Call the health care provider (HCP).
104. The nurse has a prescription to hang a 1000-mL
intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium
chloride and needs to add the medication to the IV bag. The nurse should plan
to take which action immediately after injecting the potassium chloride into the port of the
IV bag?
intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium
chloride and needs to add the medication to the IV bag. The nurse should plan
to take which action immediately after injecting the potassium chloride into the port of the
IV bag?
1. Rotate the bag gently.
2. Attach the tubing to the client.
3. Prime the tubing with the IV solution.
4. Check the solution for yellowish discoloration.
105. The nurse is completing a time tape for a 1000-mL IV
bag that is scheduled to infuse over 8 hours. The nurse has just placed the
11:00 AM marking at the 500-mL level. The nurse would place the mark
for noon at which numerical level (mL) on the time tape? Fill in the blank.
bag that is scheduled to infuse over 8 hours. The nurse has just placed the
11:00 AM marking at the 500-mL level. The nurse would place the mark
for noon at which numerical level (mL) on the time tape? Fill in the blank.
Answer: ______ mL
106. The nurse is making initial rounds on the nursing unit
to assess the condition of assigned clients. The nurse notes that a client’s
intravenous (IV) site is cool, pale, and swollen, and the solution is not
infusing. The nurse concludes that which complication has occurred?
to assess the condition of assigned clients. The nurse notes that a client’s
intravenous (IV) site is cool, pale, and swollen, and the solution is not
infusing. The nurse concludes that which complication has occurred?
1. Infection
2. Phlebitis
3. Infiltration
4. Thrombosis
107. The nurse is inserting an intravenous line into a
client’s vein. After the initial stick, the nurse would continue to advance the
catheter in which situation?
client’s vein. After the initial stick, the nurse would continue to advance the
catheter in which situation?
1. The catheter advances easily.
2. The vein is distended under the needle.
3. The client does not complain of discomfort.
4. Blood return shows in the backflash chamber of the
catheter.
catheter.
108. The nurse notes that the site of a client’s peripheral
intravenous (IV) catheter is reddened, warm, painful, and slightly edematous
proximal to the insertion point of the IV catheter. After taking appropriate
steps to care for the client, the nurse should document in the medical record
that the client experienced which condition?
intravenous (IV) catheter is reddened, warm, painful, and slightly edematous
proximal to the insertion point of the IV catheter. After taking appropriate
steps to care for the client, the nurse should document in the medical record
that the client experienced which condition?
1. Phlebitis of the vein
2. Infiltration of the IV line
3. Hypersensitivity to the IV solution
4. Allergic reaction to the IV catheter material
109. The nurse is preparing a continuous intravenous (IV)
infusion at the medication cart. As the nurse goes to insert the spike end of
the IV tubing into the IV bag, the tubing drops and the spike end hits the top
of the medication cart. The nurse should take which action?
infusion at the medication cart. As the nurse goes to insert the spike end of
the IV tubing into the IV bag, the tubing drops and the spike end hits the top
of the medication cart. The nurse should take which action?
1. Obtain a new IV bag.
2. Obtain new IV tubing.
3. Wipe the spike end of the tubing with Betadine.
4. Scrub the spike end of the tubing with an alcohol
swab.
swab.
110. A health care provider has written a prescription to
discontinue an intravenous (IV) line. The nurse should obtain which item from
the unit supply area for applying pressure to the site after removing the IV
catheter?
discontinue an intravenous (IV) line. The nurse should obtain which item from
the unit supply area for applying pressure to the site after removing the IV
catheter?
1. Elastic wrap
2. Betadine swab
3. Adhesive bandage
4. Sterile 2 × 2 gauze
111. A client rings the call bell and complains of pain at
the site of an intravenous (IV) infusion. The nurse assesses the site and
determines that phlebitis has developed. The nurse should take which action(s)
in the care of this client? Select
all that apply.
the site of an intravenous (IV) infusion. The nurse assesses the site and
determines that phlebitis has developed. The nurse should take which action(s)
in the care of this client? Select
all that apply.
1. Notify the health care provider (HCP).
2. Remove the IV catheter at that site.
3. Apply warm moist packs to the site.
4. Start a new IV line in a proximal portion of the same
vein.
vein.
5. Document the occurrence, actions taken, and the
client’s response.
client’s response.
112. A client involved in a motor vehicle crash presents to
the emergency department with severe internal bleeding. The client is severely
hypotensive and unresponsive. The nurse anticipates that which intravenous (IV)
solution will most
likely be prescribed to increase
intravascular volume, replace immediate blood loss volume, and increase blood
pressure?
the emergency department with severe internal bleeding. The client is severely
hypotensive and unresponsive. The nurse anticipates that which intravenous (IV)
solution will most
likely be prescribed to increase
intravascular volume, replace immediate blood loss volume, and increase blood
pressure?
1. 5% dextrose in lactated Ringer’s
2. 0.33% sodium chloride (⅓ normal saline)
3. 0.225% sodium chloride (¼ normal saline)
4. 0.45% sodium chloride (½ normal saline)
113. The nurse provides a list of instructions to a client
being discharged to home with a peripherally inserted central catheter (PICC).
The nurse determines that the client needs further instructions
if the client made which statement?
being discharged to home with a peripherally inserted central catheter (PICC).
The nurse determines that the client needs further instructions
if the client made which statement?
1. “I need to wear a Medic-Alert tag or bracelet.”
2. “I need to restrict my activity while this catheter is
in place.”
in place.”
3. “I need to have a repair kit available in the home for
use if needed.”
use if needed.”
4. “I need to keep the insertion site protected when in
the shower or bath.”
the shower or bath.”
114. A client has just undergone insertion of a central
venous catheter at the bedside. The nurse would be sure to check which results
before initiating the flow rate of the client’s intravenous (IV) solution at
100 mL/hour?
venous catheter at the bedside. The nurse would be sure to check which results
before initiating the flow rate of the client’s intravenous (IV) solution at
100 mL/hour?
1. Serum osmolality
2. Serum electrolyte levels
3. Portable chest x-ray film
4. Intake and output record
115. A client with the recent diagnosis of myocardial
infarction and impaired renal function is recuperating on the step-down cardiac
unit. The client’s blood pressure has been borderline low and intravenous (IV)
fluids have been infusing at 100 mL/hour via a central line catheter in
the right internal jugular for approximately 24 hours to increase renal output
and maintain the blood pressure. Upon entering the client’s room, the nurse
notes that the client is breathing rapidly and is coughing. The nurse determines
that the client is most
likely experiencing which complication of
IV therapy?
infarction and impaired renal function is recuperating on the step-down cardiac
unit. The client’s blood pressure has been borderline low and intravenous (IV)
fluids have been infusing at 100 mL/hour via a central line catheter in
the right internal jugular for approximately 24 hours to increase renal output
and maintain the blood pressure. Upon entering the client’s room, the nurse
notes that the client is breathing rapidly and is coughing. The nurse determines
that the client is most
likely experiencing which complication of
IV therapy?
1. Hematoma
2. Air embolism
3. Systemic infection
4. Circulatory overload
ANSWERS
103. 1
Rationale:
The client’s symptoms are compatible with circulatory overload. This may be
verified by noting that 600 mL has infused in the course of 45 minutes.
The first action of the nurse is to slow the infusion. Other actions may follow
in rapid sequence. The nurse may elevate the head of the bed to aid the
client’s breathing, if necessary. The nurse also notifies the HCP. The IV
catheter is not removed; it may be needed for the administration of medications
to resolve the complication.
The client’s symptoms are compatible with circulatory overload. This may be
verified by noting that 600 mL has infused in the course of 45 minutes.
The first action of the nurse is to slow the infusion. Other actions may follow
in rapid sequence. The nurse may elevate the head of the bed to aid the
client’s breathing, if necessary. The nurse also notifies the HCP. The IV
catheter is not removed; it may be needed for the administration of medications
to resolve the complication.
Test-Taking Strategy: Note the strategic word first. This tells you that
more than one or all of the options are likely to be correct actions and that
the nurse needs to prioritize them according to a time sequence. You must be
able to recognize the signs of circulatory overload. From this point, select
the option that provides the intervention specific to circulatory overload.
more than one or all of the options are likely to be correct actions and that
the nurse needs to prioritize them according to a time sequence. You must be
able to recognize the signs of circulatory overload. From this point, select
the option that provides the intervention specific to circulatory overload.
Review:
Nursing actions for circulatory overload
Nursing actions for circulatory overload
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Leadership and Management—Prioritizing
Priority Concepts: Clinical Judgment; Perfusion
Reference:
Alexander et al (2010), p. 256.
Alexander et al (2010), p. 256.
104. 1
Rationale:
After adding a medication to a bag of IV solution, the nurse should agitate or
rotate the bag gently to mix the medication evenly in the solution. The nurse
should then attach a completed medication label. The nurse can then prime the
tubing. The IV solution should have been checked for discoloration before the
medication was added to the solution. The tubing is attached to the client
last.
After adding a medication to a bag of IV solution, the nurse should agitate or
rotate the bag gently to mix the medication evenly in the solution. The nurse
should then attach a completed medication label. The nurse can then prime the
tubing. The IV solution should have been checked for discoloration before the
medication was added to the solution. The tubing is attached to the client
last.
Test-Taking Strategy: Note the strategic word immediately.
This implies a correct time sequence, and you need to prioritize. Visualize and
think through the steps of adding medication to an IV bag, and make your choice
accordingly.
This implies a correct time sequence, and you need to prioritize. Visualize and
think through the steps of adding medication to an IV bag, and make your choice
accordingly.
Review:
Reconstitution of an intravenous (IV) solution
Reconstitution of an intravenous (IV) solution
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Critical Care—Medications and Intravenous Therapy
Priority Concepts: Clinical Judgment; Safety
References:
Lewis et al (2011), p. 316; Perry, Potter, Elkin (2012), p. 568; Potter et al
(2013), p. 635.
Lewis et al (2011), p. 316; Perry, Potter, Elkin (2012), p. 568; Potter et al
(2013), p. 635.
105. 375Rationale:
If the IV is scheduled to run over 8 hours, then the hourly rate is
125 mL/hour. Using 500 mL as the reference point, the next hourly
marking would be at 375 mL, which is 125 mL less than 500.
If the IV is scheduled to run over 8 hours, then the hourly rate is
125 mL/hour. Using 500 mL as the reference point, the next hourly
marking would be at 375 mL, which is 125 mL less than 500.
Test-Taking Strategy: Focus on the subject, intravenous infusion
calculations. Use basic principles related to pharmacology math and IV
administration to answer this question. Subtract 125 from 500 to yield 375.
calculations. Use basic principles related to pharmacology math and IV
administration to answer this question. Subtract 125 from 500 to yield 375.
Review:
Administration of intravenous medications
Administration of intravenous medications
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Fundamental Skills—Medications/IV Calculations
Priority Concepts: Clinical Judgment; Safety
Reference:
Alexander et al (2010),
p. 272.
p. 272.
106. 3
Rationale:
An infiltrated IV is one that has dislodged from the vein and is lying in
subcutaneous tissue. Pallor, coolness, and swelling are the results of IV fluid
being deposited in the subcutaneous tissue. When the pressure in the tissues
exceeds the pressure in the tubing, the flow of the IV solution will stop. The
corrective action is to remove the catheter and start a new IV line at another
site. Infection, phlebitis, and thrombosis are likely to be accompanied by
warmth at the site, not coolness.
An infiltrated IV is one that has dislodged from the vein and is lying in
subcutaneous tissue. Pallor, coolness, and swelling are the results of IV fluid
being deposited in the subcutaneous tissue. When the pressure in the tissues
exceeds the pressure in the tubing, the flow of the IV solution will stop. The
corrective action is to remove the catheter and start a new IV line at another
site. Infection, phlebitis, and thrombosis are likely to be accompanied by
warmth at the site, not coolness.
Test-Taking Strategy: Focus on the subject, clinical
manifestations at the IV site. Noting the word cool in the question will direct you to the correct
option. Remember that pallor, coolness, and swelling are signs of infiltration.
manifestations at the IV site. Noting the word cool in the question will direct you to the correct
option. Remember that pallor, coolness, and swelling are signs of infiltration.
Review:
Signs of infiltration
Signs of infiltration
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Critical Care—Medications and Intravenous Therapy
Priority Concepts: Clinical Judgment; Tissue Integrity
Reference:
Alexander et al (2010), pp. 470-471.
Alexander et al (2010), pp. 470-471.
107. 4
Rationale:
The IV catheter has entered the lumen of the vein successfully when blood
backflash shows in the IV catheter. The vein should have been distended by the
tourniquet before the vein was cannulated. Client discomfort varies with the
client, the site, and the nurse’s insertion technique and is not a reliable
measure of catheter placement. The nurse should not advance the catheter until
placement in the vein is verified by blood return.
The IV catheter has entered the lumen of the vein successfully when blood
backflash shows in the IV catheter. The vein should have been distended by the
tourniquet before the vein was cannulated. Client discomfort varies with the
client, the site, and the nurse’s insertion technique and is not a reliable
measure of catheter placement. The nurse should not advance the catheter until
placement in the vein is verified by blood return.
Test-Taking Strategy: Focus on the subject of the question:
correct placement of an IV catheter. Noting the words blood return in the correct option will direct you to this
option because a blood return is expected if the catheter is in a vein.
correct placement of an IV catheter. Noting the words blood return in the correct option will direct you to this
option because a blood return is expected if the catheter is in a vein.
Review:
Insertion of an intravenous catheter
Insertion of an intravenous catheter
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Critical Care—Medications and Intravenous Therapy
Priority Concepts: Clinical Judgment; Perfusion
Reference:
Perry, Potter, Elkin (2012), pp. 662-663.
Perry, Potter, Elkin (2012), pp. 662-663.
108. 1
Rationale:
Phlebitis at an IV site can be distinguished by client discomfort at the site
and by redness, warmth, and swelling proximal to the catheter. If phlebitis
occurs, the nurse should discontinue the IV line and insert a new IV line at a
different site. Coolness at the site would be noted if the IV catheter was
infiltrated. An allergic reaction produces a rash, redness, and itching. A
major reaction, such as hypersensitivity, can cause dyspnea, a swollen tongue,
and cyanosis.
Phlebitis at an IV site can be distinguished by client discomfort at the site
and by redness, warmth, and swelling proximal to the catheter. If phlebitis
occurs, the nurse should discontinue the IV line and insert a new IV line at a
different site. Coolness at the site would be noted if the IV catheter was
infiltrated. An allergic reaction produces a rash, redness, and itching. A
major reaction, such as hypersensitivity, can cause dyspnea, a swollen tongue,
and cyanosis.
Test-Taking Strategy: Hypersensitivity and allergic reaction are comparable or alike and therefore are eliminated first. Choose the
correct option over infiltration after recalling that warmth is noted with
phlebitis and coolness is noted with infiltration.
correct option over infiltration after recalling that warmth is noted with
phlebitis and coolness is noted with infiltration.
Review:
Signs and symptoms of phlebitis
Signs and symptoms of phlebitis
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Integrated Process: Communication and Documentation
Content Area: Critical Care—Medications and Intravenous Therapy
Priority Concepts: Clinical Judgment; Communication
Reference:
Ignatavicius, Workman (2013), p. 228.
Ignatavicius, Workman (2013), p. 228.
109. 2
Rationale:
The nurse should obtain new IV tubing because contamination has occurred and
could cause systemic infection to the client. There is no need to obtain a new
IV bag because the bag was not contaminated. Wiping with Betadine or alcohol is
insufficient and is contraindicated because the spike will be inserted into the
IV bag.
The nurse should obtain new IV tubing because contamination has occurred and
could cause systemic infection to the client. There is no need to obtain a new
IV bag because the bag was not contaminated. Wiping with Betadine or alcohol is
insufficient and is contraindicated because the spike will be inserted into the
IV bag.
Test-Taking Strategy: Focus on the subject, that the tubing was
contaminated. Use knowledge of basic infection control measures and IV therapy
concepts to answer this question. Clearly, only one option is correct. Remember
that if an item is contaminated, discard it and obtain a new sterile item.
contaminated. Use knowledge of basic infection control measures and IV therapy
concepts to answer this question. Clearly, only one option is correct. Remember
that if an item is contaminated, discard it and obtain a new sterile item.
Review:
Surgical
aseptic technique
Surgical
aseptic technique
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process—Implementation
Content Area: Critical Care—Medications and Intravenous Therapy
Priority Concepts: Clinical Judgment; Infection
Reference:
Potter et al (2013), pp. 421-422.
Potter et al (2013), pp. 421-422.
110. 4
Rationale:
A dry sterile dressing such as a sterile 2 × 2 is used to apply
pressure to the discontinued IV site. This material is absorbent, sterile, and
nonirritating. A Betadine swab would irritate the opened puncture site and
would not stop the blood flow. An adhesive bandage or elastic wrap may be used
to cover the site once hemostasis has occurred.
A dry sterile dressing such as a sterile 2 × 2 is used to apply
pressure to the discontinued IV site. This material is absorbent, sterile, and
nonirritating. A Betadine swab would irritate the opened puncture site and
would not stop the blood flow. An adhesive bandage or elastic wrap may be used
to cover the site once hemostasis has occurred.
Test-Taking Strategy: Focus on the subject, care to the IV site
after removal of the catheter, and note the words applying pressure. Visualize this procedure, thinking about each
of the items identified in the options to direct you to the correct option.
after removal of the catheter, and note the words applying pressure. Visualize this procedure, thinking about each
of the items identified in the options to direct you to the correct option.
Review:
Intravenous
catheter removal
Intravenous
catheter removal
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Critical Care—Medications and Intravenous Therapy
Priority Concept:
Clinical Judgment;
Clotting
Clotting
Reference:
Ignatavicius, Workman (2013), p. 226.
Ignatavicius, Workman (2013), p. 226.
111. 1, 2, 3, 5Rationale:
Phlebitis is an inflammation of the vein that can occur from mechanical or
chemical (medication) trauma or from a local infection and can cause the
development of a clot (thrombophlebitis). The nurse should remove the IV at the
phlebitic site and apply warm moist compresses to the area to speed resolution
of the inflammation. Because phlebitis has occurred, the nurse also notifies
the HCP about the IV complication. The nurse should restart the IV in a vein
other than the one that has developed phlebitis. Finally, the nurse documents
the occurrence, actions taken, and the client’s response.
Phlebitis is an inflammation of the vein that can occur from mechanical or
chemical (medication) trauma or from a local infection and can cause the
development of a clot (thrombophlebitis). The nurse should remove the IV at the
phlebitic site and apply warm moist compresses to the area to speed resolution
of the inflammation. Because phlebitis has occurred, the nurse also notifies
the HCP about the IV complication. The nurse should restart the IV in a vein
other than the one that has developed phlebitis. Finally, the nurse documents
the occurrence, actions taken, and the client’s response.
Test-Taking Strategy: Focus on the subject, actions to take if
phlebitis occurs. Recall that phlebitis is an inflammation of the vein. This
will assist in eliminating the option that indicates to use the same vein
because an IV should be restarted in a vein other than the one that has
developed phlebitis.
phlebitis occurs. Recall that phlebitis is an inflammation of the vein. This
will assist in eliminating the option that indicates to use the same vein
because an IV should be restarted in a vein other than the one that has
developed phlebitis.
Review:
Phlebitis
Phlebitis
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Critical Care—Medications and Intravenous Therapy
Priority Concepts: Clinical Judgment; Inflammation
Reference:
Ignatavicius, Workman (2013), p. 228.
Ignatavicius, Workman (2013), p. 228.
112. 1
Rationale:
The goal of therapy with this client is to expand intravascular volume as
quickly as possible. The 5% dextrose in lactated Ringer’s (hypertonic solution)
would increase intravascular volume and immediately replace lost fluid volume
until a transfusion could be administered, resulting in an increase in the
client’s blood pressure. The solutions in the remaining options would not be
given to this client because they are hypotonic solutions and, instead of
increasing intravascular space, the solutions would move into the cells via
osmosis.
The goal of therapy with this client is to expand intravascular volume as
quickly as possible. The 5% dextrose in lactated Ringer’s (hypertonic solution)
would increase intravascular volume and immediately replace lost fluid volume
until a transfusion could be administered, resulting in an increase in the
client’s blood pressure. The solutions in the remaining options would not be
given to this client because they are hypotonic solutions and, instead of
increasing intravascular space, the solutions would move into the cells via
osmosis.
Test-Taking Strategy: Focus on the subject, that the client
requires increased intravascular volume. Also, note the strategic words most likely. Recalling IV fluid types and how hypotonic and hypertonic
solutions function within the intravascular space will direct you to the
correct option.
requires increased intravascular volume. Also, note the strategic words most likely. Recalling IV fluid types and how hypotonic and hypertonic
solutions function within the intravascular space will direct you to the
correct option.
Review:
Intravenous
fluids
Intravenous
fluids
Level of Cognitive Ability: Understanding
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Planning
Content Area: Critical Care—Medications and Intravenous Therapy
Priority Concept:
Clinical Judgment;
Perfusion
Perfusion
Reference:
Ignatavicius, Workman (2013), p. 211.
Ignatavicius, Workman (2013), p. 211.
113. 2
Rationale:
The client should be taught that only minor activity restrictions apply with
this type of catheter. The client should protect the site during bathing and
should carry or wear a Medic-Alert identification. The client should have a
repair kit in the home for use as needed because the catheter is for long-term
use.
The client should be taught that only minor activity restrictions apply with
this type of catheter. The client should protect the site during bathing and
should carry or wear a Medic-Alert identification. The client should have a
repair kit in the home for use as needed because the catheter is for long-term
use.
Test-Taking Strategy: Note the strategic words needs further instructions. These words indicate a negative event query and the need to select the incorrect client
statement. Recalling that the PICC is for long-term use will assist in
directing you to the correct option. To restrict activity with such a catheter
is unreasonable.
statement. Recalling that the PICC is for long-term use will assist in
directing you to the correct option. To restrict activity with such a catheter
is unreasonable.
Review:
Peripherally
inserted intravenous catheters
Peripherally
inserted intravenous catheters
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Critical Care—Medications and Intravenous Therapy
Priority Concepts: Client Education; Functional Ability
Reference:
Perry, Potter, Elkin (2012), pp. 658, 667.
Perry, Potter, Elkin (2012), pp. 658, 667.
114. 3
Rationale:
Before beginning administration of IV solution, the nurse should assess whether
the chest radiograph reveals that the central catheter is in the proper place.
This is necessary to prevent infusion of IV fluid into pulmonary or
subcutaneous tissues. The other options represent items that are useful for the
nurse to be aware of in the general care of this client, but they do not relate
to this procedure.
Before beginning administration of IV solution, the nurse should assess whether
the chest radiograph reveals that the central catheter is in the proper place.
This is necessary to prevent infusion of IV fluid into pulmonary or
subcutaneous tissues. The other options represent items that are useful for the
nurse to be aware of in the general care of this client, but they do not relate
to this procedure.
Test-Taking Strategy: Note the subject, care to the client
with a central venous catheter. Note the words insertion of a central
venous catheter at the bedside. Recalling the potential complications associated with the
insertion of central venous catheters will direct you to the correct option.
with a central venous catheter. Note the words insertion of a central
venous catheter at the bedside. Recalling the potential complications associated with the
insertion of central venous catheters will direct you to the correct option.
Review:
Nursing actions related to central venous catheters
Nursing actions related to central venous catheters
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Critical Care—Medications and Intravenous Therapy
Priority Concepts: Clinical Judgment; Safety
Reference:
Ignatavicius, Workman (2013), p. 216.
Ignatavicius, Workman (2013), p. 216.
115. 4
Rationale:
Circulatory (fluid) overload is a complication of intravenous therapy. Signs
include rapid breathing, dyspnea, a moist cough, and crackles. When circulatory
overload is present, the client’s blood pressure also increases. Hematoma is
characterized by ecchymosis, swelling, and leakage at the IV insertion site, as
well as hard and painful lumps at the site. Air embolism is characterized by
tachycardia, dyspnea, hypotension, cyanosis, and decreased level of
consciousness. Systemic infection is characterized by chills, fever, malaise,
headache, nausea, vomiting, backache, and tachycardia.
Circulatory (fluid) overload is a complication of intravenous therapy. Signs
include rapid breathing, dyspnea, a moist cough, and crackles. When circulatory
overload is present, the client’s blood pressure also increases. Hematoma is
characterized by ecchymosis, swelling, and leakage at the IV insertion site, as
well as hard and painful lumps at the site. Air embolism is characterized by
tachycardia, dyspnea, hypotension, cyanosis, and decreased level of
consciousness. Systemic infection is characterized by chills, fever, malaise,
headache, nausea, vomiting, backache, and tachycardia.
Test-Taking Strategy: Focus on the data in the question and note the strategic words most likely. Noting that the client is experiencing rapid breathing and is
coughing will assist in directing you to the correct option.
coughing will assist in directing you to the correct option.
Review:
Signs of circulatory overload
Signs of circulatory overload
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Analysis
Content Area: Critical Care—Medications and Intravenous Therapy
Priority Concepts: Clinical Judgment; Perfusion