Chapter 27: Intravenous and Vascular Access Therapy

Chapter 27: Intravenous and Vascular Access Therapy

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. After inserting a peripheral intravenous (IV) line into the patient, the nurse provides patient teaching about the IV insertion site. What information should the nurse give to the patient?

a.	Expect minor pain at the insertion site.
b.	Report redness at the insertion site.
c.	Remain on bed rest with the IV infusion.
d.	Disconnect IV tubing to change a gown.

 

 

ANS:  B

The nurse instructs the patient to report redness at the insertion site for early detection of IV complications, including infection and phlebitis. The IV site should cause very little discomfort if the infusion is proceeding without problems. Pain associated with an IV infusion indicates vein irritation from infusing fluid, irritating medication, infiltration, extravasatioin, infection, or phlebitis. Patients with IV infusions are not confined to bed. The nurse instructs the patient to call for help when changing the gown because, if the gown has no snaps at the shoulder, the nurse must feed the IV tubing and bag through the opening of the gown when the gown is changed.

 

DIF:    Cognitive Level: Comprehend          REF:   Page 720| Page 727

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Implementation

 

2. The nurse is trying to access the best insertion site on a patient. Which principle would the nurse use to achieve this goal?

a.	Avoid using soft, bouncy veins.
b.	Choose the patient’s best proximal vein.
c.	Choose a site large enough for adequate blood flow.
d.	Always use the smallest-gauge intravenous (IV) catheter available.

 

 

ANS:  C

The site must be large enough to prevent interruption of venous flow while allowing adequate blood flow around the catheter. The nurse chooses a site for venipuncture with soft, bouncy veins because these veins are more easily punctured and stabilized during the insertion. The most distal vein is the best for insertion to maintain the maximum number of potential sites for future use. The smallest-gauge IV catheter suitable for both the therapy and the patient’s vein should be selected.

 

DIF:    Cognitive Level: Comprehend          REF:   Page 716

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Implementation

 

3. The healthcare provider’s order reads, “Administer 5% dextrose solution with normal saline (D₅NS) intravenously now.” Which should the nurse implement next?

a.	Infuse a bolus of D5NS to the patient now.
b.	Regulate an intravenous (IV) infusion pump at 125 mL/hour.
c.	Call the healthcare provider to clarify the order.
d.	Perform venipuncture with a butterfly needle.

 

 

ANS:  C

The only recourse for the nurse is to clarify the order because it is incomplete. It is missing an infusion rate.  You would not start an IV or give the IV until you have the infusion rate information.

 

DIF:    Cognitive Level: Comprehend          REF:   Page 723

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Planning

 

4. The healthcare provider prescribes 500 mL of 0.25% normal saline (1/4 NS) intravenously over 4 hours for the patient. At which rate does the nurse infuse the intravenous (IV) solution into the patient using IV tubing with a drop factor of 15 gtts/mL?

a.	125 mL/hr
b.	31 mL/min
c.	31 gtts/min
d.	125 gtts/min

 

 

ANS:  C

500 mL  ´   1 hr    ´  15 gtts  = 31.25 gtts/min = 31 gtts/min

4 hr         60 min       1 mL

 

DIF:    Cognitive Level: Remember            REF:   Page 724

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Implementation

 

5. The prescription for the patient’s intravenous (IV) infusion reads, “100 mL/hr.” The nurse observes that the patient’s IV line infused 125 mL in addition to the ordered volume after 2 hours. Which is the most important intervention for the nurse to implement?

a.	Compare weight to baseline data.
b.	Replace the infusion pump batteries.
c.	Assess the patient for respiratory distress.
d.	Reduce the infusion rate below 75 mL/hr.

 

 

ANS:  C

The nurse assesses the patient for respiratory distress after an excessive infusion of 125 mL of IV fluid because excess total body fluid often leaks into the pulmonary vascular bed to decrease gas exchange. This may lead to hypoxemia and dyspnea because the patient has difficulty with oxygenation, and there can be enough fluid overload to precipitate heart failure in a patient with heart disease or respiratory failure in a patient with pulmonary disease. Weighing the patient is a reasonable nursing intervention to differentiate patient weight gain from fluid or caloric intake. Verifying patient safety and well-being is a better choice and is more important than differentiating the weight because the extra fluid can cause dyspnea, desaturation, and heart failure. Checking the infusion pump batteries is a reasonable intervention if the pump operates on battery power.  The nurse can reduce the infusion rate to 75 mL/hr after collaborating with the healthcare provider. The nurse cannot change the infusion rate because doing so is equivalent to practicing medicine.

 

DIF:    Cognitive Level: Analyze                REF:   Page 726

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Evaluation