IV Therapy

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with an intravenous (IV) site dressing?

• A. "Assess the IV site frequently for signs of inflammation."

• B. "Be sure not to obscure the insertion site with the dressing."

• C. "If the gauze dressing looks damp, replace it with a dry 4 × 4 gauze."

• D. "Be sure to notify me if the patient reports that the IV site is painful or swollen."

Answer explanation

D. Label the dressing with the date and time of application;

Rationale: The task of reporting a patient's complaint may be delegated to NAP. Assessment may not be delegated to NAP. No aspect of insertion site care or dressing application may be delegated to NAP. The task of changing an IV dressing may not be delegated to NAP.

https://quizlet.com/546786477/week-11-clinical-skills-flash-cards/

How will the nurse minimize the risk for infection when changing a patient's IV catheter site dressing?

• A. Use aseptic technique throughout the process.

• B. Pull the tape toward the insertion site

• C. Remove both the gauze dressing and the tape one layer at a time.

• D. Explain the process to the patient.

Answer explanation

A. Use aseptic technique throughout the process;

Rationale: Following aseptic technique will reduce the patient's risk for infection. Pulling the tape toward the insertion site would not minimize the patient's risk for infection. Removing the gauze one layer at a time would not minimize the patient's risk for infection. Explaining the process of changing the dressing would not minimize the patient's risk for infection.

Which action would the nurse take if an intravenous (IV) insertion site appeared red, warm, and swollen?

• A. Assess for blood return.

• B. Discontinue the infusion.

• C. Change the existing dressing.

• D. Secure the tubing with more tape.

Answer explanation

B. Discontinue the infusion;

Rationale: An IV site that is red, warm, and swollen suggests phlebitis or infection and the IV catheter must be removed to prevent further damage to the patient's arm. Assessing for blood return would not improve the condition of the IV insertion site. Changing the existing dressing would not improve the condition of the IV insertion site. Securing the tubing would not improve the condition of the IV insertion site.

What would the nurse do to assess a patient's risk for embolus when removing a venous access device?

• A. Inspect the site for redness.

• B. Visualize the tip of the IV device.

• C. Palpate the site for possible edema.

• D. Ask the patient to rate any pain at the site.

Answer explanation

B. Visualize the tip of the IV device;

Rationale: Damage to the tip of the device, resulting in a portion of the device remaining in the vessel, may cause an embolus to form. Inspecting the site for redness would identify phlebitis or infection, but doing so would not help assess the patient's risk for embolus. Palpating the site for possible edema would identify infiltration, but doing so would not help assess the patient's risk for embolus. Asking the patient to rate his or her pain would not help assess the patient's risk for embolus.

Which instruction might the nurse give to nursing assistive personnel (NAP) when caring for a patient whose IV access device is to be removed?

• A. "Remember to wear gloves to minimize the risk for infection."

• B. "Be sure to keep pressure on the site for at least 2 to 3 minutes."

• C. "Let me know if you notice any bleeding on the site dressing."

• D. "Make sure the patient knows to notify me if the IV site becomes painful."

Answer explanation

C. "Let me know if you notice any bleeding on the site dressing.";

Rationale: The nurse might offer this instruction because the task of reporting signs of bleeding may be delegated to NAP. The removal of an IV access device cannot be delegated to NAP. The removal of an IV access device cannot be delegated to NAP. Patient education may not be delegated to NAP.

What might the nurse do to improve a patient's cooperation during the removal of an IV access device?

• A. Describe the entire procedure to the patient.

• B. Assure the patient that you will remove the IV catheter quickly.

• C. Assure the patient that the procedure will take only about 5 minutes.

• D. Tell the patient that the procedure will cause only a slight burning sensation.

Answer explanation

A. Describe the entire procedure to the patient;

Rationale: Describing the entire procedure in advance will minimize fear and thus encourage the patient's cooperation. The patient is more likely to be cooperative if he or she understands the entire procedure. The IV device will be removed slowly and steadily. Discussing how long it will take is only one aspect of a complete description of the procedure. Telling the patient that the procedure will cause only a slight burning sensation is only one aspect of a complete description of the procedure.

What will the nurse do to prevent possible complications after removing an IV access device in a patient on anticoagulant therapy?

• A. Instruct the patient to report immediately any sign of bleeding on the site dressing.

• B. Perform hand hygiene and wear clean gloves while removing the device.

• C. Encourage the patient to keep a cold compress on the site for 15 minutes.

• D. Apply firm pressure to the site with sterile gauze for 10 minutes.

Answer explanation

D. Apply firm pressure to the site with sterile gauze for 10 minutes;

Rationale: Applying firm pressure will facilitate clotting. Maintaining pressure at the site for 5 to 10 minutes is recommended because the patient is receiving medication that prolongs the amount of time it takes for blood to clot. Instructing the patient to report immediately any sign of bleeding will not prevent complications after the device is removed. Performing hand hygiene and wearing clean gloves will not ensure the patient's safety after the device is removed. Applying a cold compress is not appropriate technique.

A health care provider prescribes 1,500 mL of normal saline to be infused over seven (7) hours. The drop factor is 15 drops/mL. The nurse should set the flow rate of the IV infusion pump at how many drops per minute (drops/minute)?

 Fill in the blanks and round your final answers to a whole number. 

Answer explanation

Correct answers:

214 mL/hour

54 drops/minute

Solving for the drops per minute (drops/minute)

Use the IV flow rate formula above.

Convert 7 hours to minutes by multiplying 7 hours to 60 minutes per hour and get 420 minutes.

Divide 1,500 mL (total infusion volume) by 420 minutes (total infusion time) to get 3.57 mL/minute.

Multiply 3.57 mL/minute to the drop factor of 15 drops/mL to get 53.55 drops per mL.

Round up your final answer to get 54 drops per minute.

https://nurseslabs.com/iv-flow-rate-nclex-practice-quiz/