Chapter 13: Infusion Therapy

MULTIPLE CHOICE

1.A nurse is caring for a client who has just had a central venous access line inserted. Which
action should the nurse take next?

2.A nurse assesses a client who has a radial artery catheter. Which assessment should the
nurse complete first?

3.A nurse teaches a client who is being discharged home with a peripherally inserted central
catheter (PICC). Which statement should the nurse include in this clients teaching?

4.A nurse is caring for a client who is having a subclavian central venous catheter inserted. The
client begins to report chest pain and difficulty breathing. After administering oxygen, which
action should the nurse take next?

5.A nurse is caring for a client who is receiving an epidural infusion for pain management.
Which assessment finding requires immediate intervention from the nurse?
6.A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which
assessment finding is of greatest concern?

7.A nurse is assessing clients who have intravenous therapy prescribed. Which assessment
finding for a client with a peripherally inserted central catheter (PICC) requires immediate
attention?

8.A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the
site. Which action should the nurse take next?

9.While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein
path and palpates a 4-cm venous cord. How should the nurse document this finding?

10.A nurse responds to an IV pump alarm related to increased pressure. Which action should
the nurse take first?
11.A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action
should the nurse take to protect the clients skin during this procedure?

12.A nurse delegates care to an unlicensed assistive personnel (UAP). Which statement should
the nurse include when delegating hygiene for a client who has a vascular access device?

13.A nurse teaches a client who is prescribed a central vascular access device. Which
statement should the nurse include in this clients teaching?

14.A nurse is caring for a client with a peripheral vascular access device who is experiencing
pain, redness, and swelling at the site. After removing the device, which action should the nurse
take to relieve pain?

15.A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client
reports abdominal pain and feeling warm. For which complication of this therapy should the
nurse assess this client?
16.A medical-surgical nurse is concerned about the incidence of complications related to IV
therapy, including bloodstream infection. Which intervention should the nurse suggest to the
management team to make the biggest impact on decreasing complications?

17.A nurse prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of
heparin. The pharmacy supplies a multi-dose vial of heparin with a concentration of 100
units/mL. Which of the syringes shown below should the nurse use to draw up and administer
the heparin?

18.A home care nurse prepares to administer intravenous medication to a client. The nurse
assesses the site and reviews the clients chart prior to administering the medication:
Client: Thomas Jackson

DOB: 5/3/1936

Gender: Male

January 23 (Today): ​Right upper extremity PICC is intact, patent, and has a good blood return.
Site clean and free from manifestations of infiltration, irritation, and infection. Sue Franks, RN

January 20: ​Purulent drainage from sacral wound. Wound cleansed and dressing changed. Dr.
Smith notified and updated on client status. New orders received for intravenous antibiotics. Sue
Franks, RN

January 13: ​Client alert and oriented. Sacral wound dressing changed. Sue Franks, RN

January 6: ​Right upper extremity PICC inserted. No complications. Discharged with home health
care. Dr.Smith

Based on the information provided, which action should the nurse take?

MULTIPLE RESPONSE
1.A registered nurse (RN) delegates client care to an experienced licensed practical nurse
(LPN). Which standards should guide the RN when delegating aspects of IV therapy to the
LPN? ​(Select all that apply.)

2.A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which
complications should the nurse assess? ​(Select all that apply.)

3.A nurse prepares to administer a blood transfusion to a client, and checks the blood label with
a second registered nurse using the International Society of Blood Transfusion (ISBT) universal
bar-coding system to ensure the right blood for the right client. Which components must be
present on the blood label in bar code and in eye-readable format? ​(Select all that apply.)

4.A nurse assists with the insertion of a central vascular access device. Which actions should
the nurse ensure are completed to prevent a catheter-related bloodstream infection? ​(Select all
that apply.)
SHORT ANSWER

1.A client is prescribed 1000 mL of normal saline to infuse over 24 hours. At what rate should
the nurse set the pump (mL/hr) to deliver this infusion? (​Record your answer using a whole
number.)​ ____ mL/hr

2.A client is prescribed 250 mL of normal saline to infuse over 4 hours via gravity. The facility
supplies gravity tubing with a drip factor of 15 drops/mL. At what rate (drops/min) should the
nurse set the infusion to deliver? (​Record your answer using a whole number.​) _____ drops/min