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. PIVCs allow for the administration of medications, fluids and/or blood products. On assessment, the nurse notes that the client's wound has eviscerated. Catheter Size and Type Selection. 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. The client is dehydrated and requires a smaller gauge catheter IV Fluid Considerations via Peripheral IV line. The nurse shades in a diagram indicating the burned surface areas. 9% sodium chloride 200 mL IV bolus: indicated - Place the client in Trendelenburg position: indicated. Edema at the infusion site C. 1 hour 2. Administer indomethacin³ B. 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. When assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload? A. Keep in mind that patients receiving multiple drugs may have absorption problems due to extended withholding of feedings, causing dehydration and malnutrition. 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. TPN The nurse is caring for a client who has a peripheral IV in place for fluid replacement. 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. 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. 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. and pallor at the catheter insertion site. 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. 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. 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. The student A patient is receiving IV therapy with an isotonic solution. 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 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. 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. ) A. 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. left upper A client who has peptic ulcer disease and a rigid abdomen When using the stable vs. What should the nurse do to safely administer the TPN? A) Administer TPN through a nasogastric or gastrostomy tube. ) -Replace the NG tube. The nurse should stop the insertion procedure when there is a break in technique. Place the IV and start intravenous fluids promptly; then request the laboratory obtain the blood specimen. Which action related to intravenous therapy should the nurse do first?, A client scheduled for surgery has arranged for an autologous transfusion. A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. auscultate lung sounds B. 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. The nurse listens to the client's bowel sounds. The student is assigned to a client who is to receive a 40 mEq infusion of potassium for a K+ level of 2. See Table 1. Obtain the client's vital signs 30 minutes prior to blood administration C. Flush the IV catheter. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who had IV fluids initiated at 0330. 2 hours 3. 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. 3- temperature. Wean the client from the TPN solution when oral intake is 40% of caloric requirements. Study with Quizlet and memorize flashcards containing terms like A nurse is calculating the drip rate prior to initiating an IV infusion. 3 hours 4. 020 D. A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. 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 nurse evaluates the following as a complication of the therapy: and more. 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. Vein to be used for therapy d. Which of the filling actions should the nurse take to secure the catheter? A) Apply an IV securement device. The client has been receiving intravenous therapy at 100 mL/hr. The provider has prescribed 1 g ceftriaxone IV. Which is the first action the nurse takes after adding the medication to the container? 1) Connect the bag to the tubing. Compare and contrast signs and symptoms along with nursing interventions for infiltration and phlebitis at an IV insertion site. ***3. 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. 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. A patient requires intravenous therapy for fluid replacement. Insert a second using a 22 gauge IV catheter, C. C) Tape the IV catheter's hub securely to the client's skin. 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. The nurse assesses the patient's upper extremities for a suitable insertion site. The nurse is caring for a client receiving patient-controlled analgesia Have the client drink fluid. 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). Peripheral IV catheters are available in a variety of sizes, most commonly ranging from 14 gauge to 24 gauge. A rigid abdomen is a manifestation of a perforated peptic ulcer and could lead to septicemia and shock. 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. Which of the following actions should the nurse take? a. The nurse is caring for a client who is receiving a blood transfusion and states, "I feel chilled and am having back pain. 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. 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. The nurse will take what action? a. The nurse should identify that which of the following findings is an indication of infiltration? A. 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 . Which of the following actions should the nurse take? Select all that apply. 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. Client presents to the ED with upper abdominal pain that radiates to the right shoulder. 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. 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. Fill the enema bag with 750 mL of warmed solution 4. Which action should the nurse take?, A client who is receiving antineoplastic medication by the intravenous (IV) route A nurse is assisting with caring for a client who will receive a unit of blood. The nurse should plan for the blood to infuse over which of the following lengths of time? a. 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. 3) Place a completed medication-added label to the bag. 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. 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. The client is dehydrated and requires a smaller gauge catheter than the 20 gauge being replaced. The nurse should recognize that which of the following findings indicates fluid volume excess? (Select all that apply. Change the feeding bag every 48 hours B. 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. 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. 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. 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. 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. The nurse can start a second IV catheter if required, but there is no need to discontinue the original one. The nurse removes the administration set from the package and applies the label to the tubing. 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. 4- heart rate. Vital signs 2. What action should the nurse take? Although an 18-gauge IV catheter is preferred for blood administration, a 20-gauge catheter is acceptable. *** 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. Skin color 3. Study with Quizlet and memorize flashcards containing terms like A client is in hypovolemic shock. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment? A. " Infuse 5% dextrose in water through the intravenous catheter. Place Study with Quizlet and memorize flashcards containing terms like 1. 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). Provide the client with a salt substitute c. 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. Which of the following findings should the The nurse is caring for a client receiving mechanical ventilation. 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. Which of the following actions by nurse is appropriate?, prac: the nurse is monitoring. Explanation: The sign that indicates infiltration when a client is receiving fluid through a peripheral IV catheter is skin blanching. Change the infusion tubing b. 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. Client is awake, alert, and oriented x3. Carefully reinsert Catheter Size and Type Selection. Types of Intravenous Fluids. A nurse is planning care for a client who has experienced excessive fluid loss. The nurse checks the IV site and determines that the client has developed phlebitis. 9% sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips. C. 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. 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. Exhibit 1 Nurses' Notes Day 1: Lactated Ringer's at 100 mL/hr infusing into a 20-gauge IV catheter in left hand. History and Physical Three days ago:Current diagnoses- type 2 diabetes mellitusPast medical history- left below the knee amputation 5 years ago. (Select all that apply. What nursing diagnosis is most appropriate for this client? A nurse is caring for a client who received IV calcium. Ensure that an x-ray is completed to confirm placement. Client rates pain as 7 on a scale of 0 to 10. 4 hr d. A nurse is caring for a client who is receiving dialysis treatment. Just before the infusion, it is most important for the nurse to assess the client's: 1. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a patient with a jejunostomy tube receiving intermittent enteral feedings. The nurse reduces the IV rate and notifies the physician. c. Osmolarity of the solution c. Obtain a capillary blood glucose four times daily. If they go through air or fluid, the tones are louder. The nurse is planning care for a client who is receiving antimetabolite chemotherapy. the nurse notes that the area of the arm immediately surrounding the insertion site is red and feels warm. ), 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. 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. , 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. 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. measure urine output C. 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. [8] Definition of terms. 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. 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. 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. d. 2 - Elevate the extremity. B. Chill the formula prior to administration C. Apply heat to the client's left hand. 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. See also: IV Fluids and Solution Cheat Sheet. Which items should the nurse document? Select all that apply. After the nurse inserts the IV catheter, the client reports pain in the insertion area. The respiratory system adjusts by increasing the rate and depth of breathing to increase the flow of carbon dioxide through the lungs. IV dressing dry and intact. ) Blood should not be run A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. 3 - Discontinue the IV line. The loudest tones are over the lungs and hollow stomach. Hyponatremia d. B) Wrap tape around the circumference of the client's arm. b. 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. ensure that anticoagulants are placed on hold for the duration of IV therapy. D) Place a piece of paper tape over the insertion site. Ensure an x-ray is completed to confirm placement. , 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 preparing to remove a client's peripheral IV catheter. Why would the physician designate the slower infusion rate for this client? The client may have cardiac or renal disorders. Adding potassium and antibiotic to the dialysate bags b. Stop the IV infusion. Which of the following findings should the nurse expect? (Select all that apply. Purulent c. 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. 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). ' 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. , 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. Crystalloids . Which of the following actions should the nurse take? A nurse is caring for a client who received IV calcium. Taut skin around the IV catheter site that is cool to the touch. In the past 4 hours, the patient received dextrose 5% with 0. "I will thread the needle all the way into the vein until the hub rests against the insertion site after I see 1. Check medication calculations with a second RN. 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. The nurse is assessing the client. 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. 0530: indicated - Administer a 0. 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. ask about increased thirst B. a client who is receiving an iv med. 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. Avoid sites that are areas of flexion. 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. 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. Place a pressure dressing over the IV site. 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. [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. These signs and symptoms are indicative of: -phlebitis. 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. 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. The nurse should expect which of the following laboratory findings? 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. -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. Which of the following should The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). Air embolism is a critical situation; if it is suspected, the client should be placed in a left side-lying position. 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). Administer prescribed medications through a secondary port on the TPN IV tubing. A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. IV site without redness or swelling. A PICC line is a long catheter inserted through the veins of the antecubital fossa. Leave the roller clamp slightly open. Catheters with a smaller gauge (i. 5 - 5. Which intervention would be the highest priority to reduce the risk of aspiration for this patient? Omitted A. 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. Discuss appropriate selection of IV catheter type and size. Which action should the nurse take next? a. ), 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. 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. 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. The client complains of pain when the nurse gently palpates the area. What does the nurse include in the note? Select all that apply. During her assessment, the nurse notes that the patient is having more labored respirations, and that crackles have developed in the patient’s lungs. 2. Which of the following assessments will the nurse prioritize as a result of this finding? A. Assessment of the client reveals elevated plasma calcium levels. Shake the TPN solution prior to administration if it contains oily globules. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure? A. Which action should the nurse implement? a) Stop the infusion and notify the healthcare provider of the findings. 2- hemoglobin level. A nurse is caring for a client. A nurse has just inserted a peripheral IV catheter. Which of the following actions by the nurse is appropriate?, A nurse is monitoring a client who is receiving an IV medication. 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. A peripheral intravenous catheter (PIVC) is a thin plastic tube inserted into a vein using a needle. [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. 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. The client reports pain at the insertion site and the nurse notes fluid leaking around the catheter. 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. 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. The nurse is caring for a client receiving mechanical ventilation. Increase Infusion Rate D. 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. Where should the nurse look for this information? 1. The nurse writes on the plan to check the IV of an assigned client who is receiving fluid replacement therapy at least every: 1. Exhibit 1 Nurses' Notes Day 1: Lactated Ringer's at 100 mL/hr infusing into a 20-guage IV catheter in left hand. 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. Day 2: A nurse is caring for a client who is receiving IV fluids to correct dehydration. Positioning the client on his side c. 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. A peripheral catheter can be used for the administration of peripheral parenteral nutrition for 5 to 7 days. 5 mEq/L. In which of the The client currently has D5W infusing through a 20-gauge IV catheter. Specific type of IV fluid, 2. 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. Administer IV fluids to the client evenly over 24 hr b. How will the nurse document this complication related to IV therapy? 3. 9% sodium chloride IV at 125 mL/hr. Insert an intravenous catheter. An older adult client is receiving intravenous (IV) fluid. Which of the following findings should the nurse identify as infiltration of the IV infusion site?, A nurse is preparing to insert an indwelling urinary catheter for a male client. -Place the client in Sims' position. 2 hr c. 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. Which of the following actions should the nurse take? A. 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. Based on these assessment findings, what will the nurse do next? Remove the peripheral intravenous catheter. Sanguineous d. ) Sodium 165 mEq/L B. ) Potassium 5. 4 hours. Which of the following documentation should the nurse include. 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. IV therapy. The client who has taut skin around the IV catheter site that is cool to touch might have an infiltrated IV site. 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. Prime the Y-line tubing with dextrose 5% in water B. b) Check the line for blood return and irrigate the peripheral IV catheter. help determine total body water and is recommended due to the risk for decreased intake and increased The nurse is caring for a client who is receiving peritoneal dialysis (PD). Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to administer an IV medication to a client. 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. 6. 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. Which of the following interventions should the nurse implement in caring for the client? Select all that apply. Based on these assessment findings, what will the nurse do next? Decrease the rate of the intravenous fluids. 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. I think I may have pulled it out. 8. 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. ), A nurse in an emergency A nurse is caring for a client with an IV catheter in place for fluid administration. 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. The nurse notes that the part of the arm immediately surrounding the insertion site is red and feels warm. 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. Total Parenteral Nutrition (TPN feeding) is a method of administration of essential nutrients to the body through a central vein. 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). The client states, "I was getting out of bed and caught my IV on the siderail. Which should the nurse include for this type of data collection? Select all that apply. Which of the following actions should the nurse take?, A nurse is assessing a client who is receiving told her parenteral nutrition (TPN). On rounds, the nurse notes that the client's IV site and arm are swollen and cool to the touch. client care implemented per standing orders. 2 mEq/L C. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's: 1- blood pressure. The nurse should also monitor the client's urinary output by inserting an indwelling catheter. Which interventions are appropriate when caring for a client receiving mechanical ventilation? Select all that apply. Oxygen saturation 4. The nurse notes the catheter site is warm and painful to touch. 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. Which Fluids and how much fluids to use Refer to the Intravenous Fluids RCH Clinical Practice Guideline: Intravenous Fluids. An infant's body weight is 70% to 80% water content. 4 - Apply warm, moist heat. ANS: The nurse is caring for a client who is receiving peritoneal dialysis (PD). 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. This can result in swelling and coolness at the site. " The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. The nurse notes edema, skin blanching, and tightness around the client's IV site. Which nursing intervention has the greatest priority when performing a dialysis exchange? a. A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Elevate the client's left arm. • 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. Place the client on intake and output measurement. D. The nurse notes that the area of the arm immediately surrounding the insertion site is red and feels warm. 5% will require central venous line access due to the risk of vascular endothelial damage. since admission with Lactated Ringers (LR) as the intravenous solution. Change bags of IV solution every 72 hours. 1. Insert the tubing into the client's rectum toward the umbilicus 5. Hyperkalemia c. 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. 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. A client who has peptic ulcer disease and a rigid abdomen is unstable. Hyperglycemia b. The nurse notes that the area of the am immediately surrounding the insertion site is red and feels warm. 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. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client in the emergency department (ED). The health care provider has just written an order to discontinue this therapy according to policy. 2) Rotate the bag to distribute the medication. 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. hypoactive bowel sounds C. Which of the following would the nurse suspect?, A nurse needs to administer a prescribed medication to a client using IV push. 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. Have a second 389. The nurse notes that the client has gained 6 pounds since last weeks visit. 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. The IV fluids are infusing at 120 mL/hr. Maintaining the client in a supine position. The nurse starts the infusion and checks the insertion site as per protocol. TPN Study with Quizlet and memorize flashcards containing terms like A nurse is administering IV fluids to a client. The nurse intervenes first by administering the following prescribed treatment:, A client is receiving support through an intra-aortic balloon counterpulsation. ) Urine specific gravity 1. 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. , 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. e. monitor bp readings D. Intravenous catheter size b. 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. The nurse should document this drainage as which of the following? a. 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. increased urine specific gravity B. All pulses The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). 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. On the basis of this assessment, the nurse first: A Removes the IV catheter B Slows the rate of infusion C Notifies the A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following interventions should the nurse include in the plan of care? (Select all that apply) a. When entering the room, the nurse notes that the A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. 4. The order was written to administer the fluid at a slower rate than what the nurse expected. The nurse discovers that the intravenous site is red, edematous, and painful. 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). A nurse is checking the insertion site of a peripheral IV catheter. 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. Always secure a peripheral IV catheter with tape or a stabilization device to avoid accidental dislodgement. , larger diameter) permit infusion of viscous fluids, such as blood products, at a faster rate with decreased opportunity for catheter occlusion. 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. 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. 1 hr b. Remove the IV catheter This client's manifestations suggest phlebitis. On the basis of this assessment, the nurse should take which action first? Remove the IV catheter Slow the rate of Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is receiving total parenteral nutrition and develops refeeding syndrome. The nurse notices that the client has a full, bounding pulse, dyspnea, and jugular venous distention. Identify modifications for performing IV therapy across the life span. The catheter for the balloon is inserted in the right femoral artery. Wrist restraints are applied after less-restrictive safety measures have been ineffective. Based on these assessment findings, A critical care nurse is caring for a patient diagnosed with acute pancreatitis. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority? A. 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. the percussion tones are quiet or flat. 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. Change the infusion tubing. 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. Administer a dose of an antiemetic prescribed PRN to Study with Quizlet and memorize flashcards containing terms like 1. 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. Assessing breath sounds and chest movement regularly. (IV) catheter. Which of the following actions should the nurse perform first? 1 - Check for a blood return. Flush the IV catheter c. Which of the following interventions should the nurse include in the plan? a. During the most recent check, the nurse observes that the IV has infiltrated so the nurse stops the infusion. Study with Quizlet and memorize flashcards containing terms like A patient is receiving IV therapy with an isotonic solution. Using sterile technique when hooking up dialysate bags d. -an infiltration. Nursing Care of Patients Receiving Intravenous Therapy. 3b for a list of systemic complications, signs, symptoms, and treatment. 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. When caring for the client's IV site, the nurse should: A. Physical Examination Client presents to the ED with upper abdominal pain that radiates to the right shoulder. 32. The nurse notes swelling and coolness at the site along with an absent blood return. unstable approach to client care, the nurse should assess this client first. 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. 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 if the following sites should the nurse plan to use to obtain the blood specimen? A. The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). What action will the nurse take next? a. 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. Infiltration occurs when the IV fluid leaks into the surrounding tissues instead of entering the vein. 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. 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. , A nurse is assessing a client who is receiving 0. Warmth at the infusion site D. 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. Serous b. -a systemic blood infection. 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. 9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following interventions should the nurse implement to prevent infection? A nurse is caring for a client receiving IV fluids. apply firm pressure over the vein. Assess the client for pitting edema d. The client reports burning at the IV site. 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. Which of the following actions should the nurse take? (Click on the audio button to listen to the clip. replace the IV dressing with a new, clean dressing if it is soiled. A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. 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. Note that the lower the gauge size, the wider the diameter of the catheter, with 14-gauge catheters allowing for the greatest flow rate. The infusion is sluggish, and the client reports discomfort at the site. Client also reports nausea, vomiting, and dyspepsia. Which of the following Study with Quizlet and memorize flashcards containing terms like A nurse is preparing an intravenous infusion. Flashcards; Learn; Test; Match; Q-Chat; A client is receiving intravenous (IV) fluids through a minidrop or microdrop. which of the following actions should the nurse take?-change the infusion tubing-flush the IV catheter-remove the IV catheter-apply a Study with Quizlet and memorize flashcards containing terms like The nurse is preparing to administer fluid replacement to a client. Which of the following actions should the nurse take? (Select all that apply. 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. Intravenous (IV) therapy is an important part of clinical care. The nurse observes the client's arm is edematous, and the skin feels cool to the touch. Remove the IV catheter. 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. 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. Explain nurse management of IV therapy and peripheral IV access devices. IV fluid infusing well. Lung sounds clear bilaterally, S1 and S2 heart tones noted. ) 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. 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. During the first 10 to 15 minutes of administration, which of the following assessments is the nurse's priority. 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. Flush tubing with 20 mL water after feeding is completed. 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. Inspect the IV solution for fluid color, clarity, and expiration date Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump. The client is receiving IV fluids through an IV catheter inserted in the basilic vein of the right forearm. 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. (a) 4. , A nurse is accessing a client's Hickman catheter in order to administer a prescribed IV medication. While assessing one client's peripheral IV site, the nurse notes edema around the insertion site. 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. Begin the prescribed infusion via the new access. Which opioid analgesic can be administered through iontophoresis via PCTS? A) Oxycodone B) Fentanyl C) Codeine D) Morphine. 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. Administering fluids containing glucose concentration greater than 12. Administering sedatives to maintain client comfort. Insert an indwelling urinary catheter. 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. 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. Client is awake, Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is receiving dextrose 5% water with 20 mEq of potassium chloride at 75 mL/hr. Which of the following interventions should be included in the plan of care? (Select all that apply. Day 2: IV site edematous. There are two types of fluids that are used for intravenous drips; crystalloids and colloids. ) 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. Pull the catheter straight back from the insertion site. Ensure the client's IV solution is changed every 48 hours B. 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. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. Explain the principles of peripheral intravenous site selection and contraindications. Infiltration can be caused by piercing the vein, excessive patient movement, a dislodged or incorrectly placed IV catheter, or too rapid infusion of fluids or medications into a fragile vein. A) 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. 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. 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. Change the tube infusion tubing Flush the IV catheter Remove the IV catheter Apply a cool compress to the site. Redness at the infusion site B. Aspirate the medication from the peripheral catheter. qbny wfvg qsrcda efw zoaxl xxaqk ytgwsb zhr hbolel gao