A nurse is caring for a client who is receiving fluid through a peripheral iv catheter

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