Test Bank for Phillips's Manual of I.V. Therapeutics Evidence-Based Practice for Infusion Therapy 8t

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Phillips's Manual of I.V. Therapeutics Evidence-Based Practice for Infusion Therapy 8th Edition Lisa Gorski 2023

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Phillips's Manual of I.V. Therapeutics Evidence-Based Practice for Infusion Therapy 8th Edition by Lisa Gorski.

ISBN-10 1719646090 ISBN-13 978-1719646093

Test bank for Phillips's Manual of I.V. Therapeutics Evidence-Based Practice for Infusion Therapy 8th Edition by Lisa Gorski

ISBN-10 1719646090 ISBN-13 978-1719646093

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TABLE OF CONTENTS Chapter: 1.An Overview of Professional Practice Issues and Infusion Therapy Chapter: 2.Infection Prevention and Occupational Risks Chapter: 3.Fundamentals of Fluid and Electrolyte Balance Chapter: 4. Infusion Fluid Administration Chapter: 5.Infusion Equipment Chapter: 6.Peripheral I.V. Catheters: Initiation and Management Chapter: 7.Phlebotomy Techniques Chapter: 8.Central Venous Access Chapter: 9.Complications of Infusion Therapy: Peripheral and Central Vascular Access Devices Chapter: 10.Infusion Medication Safety, Methods, and Routes Chapter: 11.Transfusion Therapy Chapter: 12.Parenteral Nutrition Chapter: 13. Introduction to Biologic Infusion Therapie

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Chapter 1: Professional Practice Concepts for Infusion Therapy Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A nurse is attempting to initiate I.V. therapy for a client diagnosed with gastroenteritis. The client is combative and resists the nurse’s efforts to start the I.V. Which action by the nurse would result in an intentional tort?

A. Failing to document the client’s combativeness B. Refusing to wear gloves while starting the I.V. C. Failing to report the client’s combativeness to a physician D. Starting an I.V. on a coherent client against the client’s wishes

2. A nurse who is caring for clients understands that he or she should provide care that meets at least the minimum standards of practice for nursing. Which phrase regarding standards of practice is most accurate?

A. Standards of practice focus on the care provider and define needed activities and behaviors.

B. Standards of practice focus on the recipient of care and describe the outcomes of care.

C. Standards of practice are written laws enacted by the legislature.

D. Standards of practice are the result of the performance of a function or process.

3. Which incident would cause a nurse to be named as a defendant in a malpractice suit?

A. The nurse notes blood return noted in a peripheral IV catheter line.

B. The nurse reports early signs of infection from a peripheral line inserted by a nurse on another unit C. The nurse places two peripheral IV catheters in a patient requiring emergency IV fluids, but only uses one D. The nurse records nerve damage caused by a peripheral IV catheter inserted the previous shift nurse

4. The intravenous route is the most commonly used infusion route. The nurse notes that a client diagnosed with metastatic cancer is receiving an intraosseous infusion. Should the nurse question the healthcare provider’s order?

A. Yes; the healthcare provider is not following INS recommendations.

B. No; the nurse should never question the healthcare provider’s order when it comes to chemotherapy.

C. Yes; this route of infusion is dangerous and not accepted by the INS. D. No; other routes might be appropriate for administration in certain situations and with selected fluids and medications.

5. Which competency assessment method is acceptable for nursing competencies which will occur once per year in the skilled nursing facility?

A. Client Evaluation B. Clinical Data C. Sentinel Event Report D. Skills Checklist

6. One of the primary values of the INS designation of CRNI (certified registered nurse, infusion) is to: A. Protect the public B. Attain competence C. Reflect a measurable goal D. Hold nurses accountable

7. Which problem-solving approach to clinical practice is the nurse manager applying when determining patient preference and values for successful clinical outcomes?

A. Effective health-care practice B. Evidence-based practice (EBP) C. Answering a burning clinical question D. One’s own clinical expertise

8. Seven days ago the PICC nurse inserted a PICC line into the right forearm of a client diagnosed with cancer.

When the nurse checks the client's site today, which nursing process outcome is determined?

A. Evaluating cancer treatment B. Implementing asepsis maintenance C. Planning for complication prevention D. Discussing prior cancer therapy

9. Which compensatory model has been applied if the hospitalization rate for CLABSIs (central line-associated bloodstream infections) decreased significantly over the last quarter?

A. VBP B. HHRP C. HAC D. HHVBP

10. When called as an expert witness in an upcoming case, the nurse manager employs which techniques?

A. Examines evidence and give advice B. Reviews charts and assesses jury selection

C. Gives deposition and notifies lawyers of discrepancies D. Testifies and establishes standards of care

Multiple Response Identify one or more choices that best complete the statement or answer the question.

1. A nurse is caring for multiple clients in a rehabilitation facility. During the shift, the nurse notes that several clients are on high-risk medications. According to the Risk Evaluation and Mitigation Strategy (REMS) program, when can the U.S. Food and Drug Administration (FDA) require a REMS? (Select all that apply.)

A. Before FDA drug approval B. After FDA drug approval C. During a client evaluation D. At an ethics committee meeting E. After client informed consent

2. A new infusion clinic is being started. The nursing supervisor of the new clinic must conform to specific standards of practice when developing nursing policies and procedures for the new program. To which organizational standards of practice must the nurse manager adhere? (Select all that apply.)

A. Centers for Disease Control and Prevention (CDC) guidelines B. Infusion Nurses Society (INS) standards C. American Medical Association (AMA) standards D. Oncology Nursing Society (ONS) standards E. U.S. Food and Drug Administration (FDA)

3. A staff nurse is serving on a hospital’s quality-assurance improvement task force. On which quality-assurance improvement models is the task force most likely to focus? (Select all that apply.)

A. Standards of care B. Standards of practice C. Performance improvement D. Continuous quality improvement E. Total Quality Management (TQM)

4. Which methods should the nurse use to evaluate achievement of client outcomes prior to discharge? (Select all that apply.)

A. Collect data to determine whether standards were met.

B. Identify controllable or uncontrollable variables.

C. Determine the cause of the problem by comparing actual care with established standards.

D. Re-evaluate to determine whether corrective action is effective and improvement in service is obtained.

E. Contact The Joint Commission (JCAHO) Web site for standards.

5. While caring for a client, a nurse administers an incorrect dose of medication, causing the client to become ill. The nurse reports the incident to the nurse manager on the unit. The nurse manager then notifies risk management. Which risk-management strategies should be used by the nurse in this situation?

(Select all that apply.)

A. Documentation B. Physical assessment C. Unusual occurrence reports D. Professional liability insurance E. Systemic analysis of serious adverse events

6. When nurses provide care to clients, nursing actions are governed by established standards of nursing care, as well as both state and federal laws. Which are sources of law? (Select all that apply.)

A. Constitution B. Statutes C. State Nurse Practice Acts D. Joint Commission standards E. Centers for Disease (CDC) standards.

7. The nursing supervisor of a new infusion clinic must conform to specific standards of practice when developing nursing policies and procedures for the new program. Which INS risk management strategies help decrease the risk of potential liability to the new clinic? (Select all that apply.)

A. Analysis of unusual occurrences B. Root cause analysis of sentinel events C. Evaluation of all patient data and surveys D. Comprehensive and thorough documentation E. Reduction of CLABSI related complications

8. While taking care of a client with multiple sclerosis, the infusion nurse inadvertently gives the client too much alemtuzumab by infusing longer than the recommended two hours. The nurse is proven negligent by which elements of the malpractice claim? (Select all that apply.)

A. The nurse has a duty to provide safe, effective treatment.

B. The nurse allows the client’s family to watch the infusion.

C. The client suffers difficulty breathing and chills during the infusion.

D. A breach of care occurs because the nurse administered too much medication.

E. The nurse should have offered the P.O. form of alemtuzumab.

9. With in-depth knowledge of community resources, which skill will help the home care infusion nurse provide

the best care? (Select all that apply.)

A. Meticulous evidence-based care B. Interprofessional communication and collaboration C. Appropriate parenteral nutrition and IV medication D. Ability to write home infusion therapy policy and procedures E. Safe, effective, and competent care

10. A nurse fails to document that an injectable heparin has been given to a client for two weeks. Upon investigation it is determined that the heparin was not given and the nurse was reported to the state board of nursing. Which type of law is the state board using? (Select all that apply.)

A. Public law B. Administrative law C. Common law D. Constitutional law E. Statutory law

Chapter 1: Professional Practice Concepts for Infusion Therapy Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A nurse is attempting to initiate I.V. therapy for a client diagnosed with gastroenteritis. The client is combative and resists the nurse’s efforts to start the I.V. Which action by the nurse would result in an intentional tort?

A. Failing to document the client’s combativeness B. Refusing to wear gloves while starting the I.V. C. Failing to report the client’s combativeness to a physician D. Starting an I.V. on a coherent client against the client’s wishes ANS: D Page: 28

A. B. C. D.

Feedback Failure to document does not result in direct injury or harm to a client and is, therefore, not an intentional tort.

Refusing to wear gloves may inadvertently result in injury or harm, but is not considered an intentional tort.

Failure to report the behavior to a physician does not result in direct injury or harm to the client and is not considered an intentional tort.

Intentional torts include assault and battery, false imprisonment, using restraints as a form of false imprisonment, defamation of character, and breach of confidentiality.

2. A nurse who is caring for clients understands that he or she should provide care that meets at least the minimum standards of practice for nursing. Which phrase regarding standards of practice is most accurate?

A. Standards of practice focus on the care provider and define needed activities and behaviors.

B. Standards of practice focus on the recipient of care and describe the outcomes of care.

C. Standards of practice are written laws enacted by the legislature.

D. Standards of practice are the result of the performance of a function or process.

ANS: A Page: 16

A.

B.

Feedback Standards of practice are criteria for measuring performance against the optimal achievable degree of clinical excellence. These standards are formulated to communicate expectations of nursing practice. Agencies are influential in developing standards of practice.

Standards of practice criteria focus on the care provider, not the care recipient

C. D.

Standards of practice are evidence-based guidelines, policies, or protocols not written laws.

Standards of practice may occur in response to unanswered questions, limited research, and/or performance issues; not necessarily the result of the performance or process.

3. Which incident would cause a nurse to be named as a defendant in a malpractice suit?

A. The nurse notes blood return noted in a peripheral IV catheter line.

B. The nurse reports early signs of infection from a peripheral line inserted by a nurse on another unit C. The nurse places two peripheral IV catheters in a patient requiring emergency IV fluids, but only uses one D. The nurse records nerve damage caused by a peripheral IV catheter inserted the previous shift nurse ANS: D Page: 29

A. B. C. D.

Feedback Blood return at the catheter site is normal.

Reporting early signs of infection is expected.

Using one peripheral IV catheter may be warranted.

The nurse had a duty to do no harm to the client and the client suffered actual harm or injury.

4. The intravenous route is the most commonly used infusion route. The nurse notes that a client diagnosed with metastatic cancer is receiving an intraosseous infusion. Should the nurse question the healthcare provider’s order?

A. Yes; the healthcare provider is not following INS recommendations.

B. No; the nurse should never question the healthcare provider’s order when it comes to chemotherapy.

C. Yes; this route of infusion is dangerous and not accepted by the INS. D. No; other routes might be appropriate for administration in certain situations and with selected fluids and medications.

ANS: D Page: 3

A.

B.

Feedback Infusion Nurses Society (INS) Standards, infusion therapy is provided with attention to safety and quality with individualized care that is collaborative, culturally sensitive, and age appropriate.

If there are questions about care the nurse (and client) should feel comfortable

C.

D.

enough to ask the healthcare provider and evidence-based criteria should be the basis for practice answers.

This is an acceptable router per INS standards. There are risks, some complications are serious and even life-threatening, and many complications are preventable with sound nursing care. The nurse must have a thorough understanding and knowledge of the type of access device being utilized, potential complications of infusion solutions, and safe infusion administration.

The intravenous (I.V.) route is the most commonly used infusion route; however, other infusion routes include intraosseous, subcutaneous, and intraspinal. In this case, the intraosseous route might be appropriate for administration with the selected fluids and medications.

5. Which competency assessment method is acceptable for nursing competencies which will occur once per year in the skilled nursing facility?

A. Client Evaluation B. Clinical Data C. Sentinel Event Report D. Skills Checklist ANS: D Page: 4

A. B. C. D.

Feedback Client evaluation is concern that may drive competency validation, but is not a method of competency assessment.

Clinical data is based on outcome criteria that drives competency validation, but is not a method of competency assessment.

Sentinel event reports are another form of competency validation, but they are not methods of competency assessment.

Competency assessment methods include performance measures related to patient care, such as skills, knowledge, ability, and judgement that includes objective, measureable assessment of the actual performance in the form of checklists.

6. One of the primary values of the INS designation of CRNI (certified registered nurse, infusion) is to: A. Protect the public B. Attain competence C. Reflect a measurable goal D. Hold nurses accountable ANS: A Page: 6

A. B.

Feedback Certification is a mark of excellence, validates nursing knowledge and skills, and protects the public.

An INS Standard is that the clinician is responsible and accountable for attaining

C. D.

and maintaining competence with infusion therapy administration and venous access device insertion/management.

Competency statements need to reflect a measurable goal.

All professional nurses are accountable and responsible for all parts of the tasks associated with infusion therapy.

7. Which problem-solving approach to clinical practice is the nurse manager applying when determining patient preference and values for successful clinical outcomes?

A. Effective health-care practice B. Evidence-based practice (EBP) C. Answering a burning clinical question D. One’s own clinical expertise ANS: B Page: 7

A. B. C. D.

Feedback Effective health-care practice is an essential characteristic of evidence-based practice.

EBP is a problem-solving approach to clinical practice and administrative issues that integrates patient preference and values.

EBP is a systematic search for and critical appraisal of the most relevant evidence to answer a burning clinical question.

EBP is a problem-solving approach that integrates one’s own clinical expertise.

8. Seven days ago the PICC nurse inserted a PICC line into the right forearm of a client diagnosed with cancer.

When the nurse checks the client's site today, which nursing process outcome is determined?

A. Evaluating cancer treatment B. Implementing asepsis maintenance C. Planning for complication prevention D. Discussing prior cancer therapy ANS: A Page: 13

A.

B. C. D.

Feedback As the cancer treatment begins, the evaluation phase begins. The plan of care should be based on the conclusion that the outcome has not been met at this time.

Maintenance of asepsis is the implementation or action plan of the nursing process.

Planning utilizes techniques to prevent complications Discussion of prior cancer therapy is a subjective assessment.

9. Which compensatory model has been applied if the hospitalization rate for CLABSIs (central line-associated

bloodstream infections) decreased significantly over the last quarter?

A. VBP B. HHRP C. HAC D. HHVBP ANS: C Page: 18

A. B. C. D.

Feedback Value-based purchasing (VBP) is a pay-for-performance program mandated by the Affordable Care Act (ACA).

Hospital readmissions reduction program (HRRP) is a pay-for-performance program mandated by the Affordable Care Act (ACA).

Hospital-acquired conditions (HAC) pay-for-performance program mandated by the Affordable Care Act (ACA). CLABSIs are hospital acquired.

Home health value-based purchasing is a model pay-for-performance program implemented for home health.

10. When called as an expert witness in an upcoming case, the nurse manager employs which techniques?

A. Examines evidence and give advice B. Reviews charts and assesses jury selection C. Gives deposition and notifies lawyers of discrepancies D. Testifies and establishes standards of care ANS: A Page: 30

A. B. C. D.

Feedback Serving as an expert witness involves examining evidence, reviewing nursing literature, giving depositions, and testifying in court.

Reviewing charts and assessing jury selection are not functions of an expert witness.

Expert witnesses do not notify lawyers of discrepancies.

Establishing standards of care is not a function of an expert witness.

Multiple Response Identify one or more choices that best complete the statement or answer the question.

1. A nurse is caring for multiple clients in a rehabilitation facility. During the shift, the nurse notes that several clients are on high-risk medications. According to the Risk Evaluation and Mitigation Strategy (REMS) program, when can the U.S. Food and Drug Administration (FDA) require a REMS? (Select all that apply.)

A. Before FDA drug approval B. After FDA drug approval C. During a client evaluation D. At an ethics committee meeting E. After client informed consent ANS: A, B Page: 19

A. B.

C. D. E.

Feedback Before approval of the drug if the FDA determines a REMS is necessary to ensure that the benefits of the drug outweigh the risks.

Postapproval if the FDA becomes aware of new safety information and determines that a REMS is necessary to ensure that the benefits of the drug outweigh the risks.

The FDA does not require a REMS during a client evaluation.

The FDA does not require a REMS at an ethics committee meeting.

The FDA does not require a REMS after client informed consent.

2. A new infusion clinic is being started. The nursing supervisor of the new clinic must conform to specific standards of practice when developing nursing policies and procedures for the new program. To which organizational standards of practice must the nurse manager adhere? (Select all that apply.)

A. Centers for Disease Control and Prevention (CDC) guidelines B. Infusion Nurses Society (INS) standards C. American Medical Association (AMA) standards D. Oncology Nursing Society (ONS) standards E. U.S. Food and Drug Administration (FDA)

ANS: A, B, D Page: 6, 9, 16

A. B. C.

Feedback The nurse manager must adhere to the guidelines of the CDC. The nurse manager must adhere to the guidelines of the INS. The AMA does not provide guidelines for nursing standards of practice.

D. E.

The nurse manager must adhere to the guidelines of the ONS. The FDA does not provide guidelines for nursing standards of

3. A staff nurse is serving on a hospital’s quality-assurance improvement task force. On which quality-assurance improvement models is the task force most likely to focus? (Select all that apply.)

A. Standards of care B. Standards of practice C. Performance improvement D. Continuous quality improvement E. Total Quality Management (TQM) ANS: B, C, D, E Page: 15–17

A. B. C.

D. E.

Feedback Standards of practice care focus on the provider, and define the activities and behaviors needed to achieve patient outcomes.

The task force is most likely to focus on Standards of practice. This as a qualityassurance model focuses on the recipient of care.

The task force is most likely to focus on Performance improvement. This quality-assurance model focuses on the recipient of care as a quality-assurance model.

The task force is most likely to focus on Continuous quality improvement . This quality-assurance model focuses on the recipient of care.

Total quality management (TQM) is a quality-assurance model that focuses on maximizing customer satisfaction.

4. Which methods should the nurse use to evaluate achievement of client outcomes prior to discharge? (Select all that apply.)

A. Collect data to determine whether standards were met.

B. Identify controllable or uncontrollable variables.

C. Determine the cause of the problem by comparing actual care with established standards.

D. Re-evaluate to determine whether corrective action is effective and improvement in service is obtained.

E. Contact The Joint Commission (JCAHO) Web site for standards.

ANS: A, B, C, D Page: 36

A.

Feedback Collection is part of the nursing process.

B. C. D. E.

Identification is part of the nursing process.

Determination of the cause of the problem is part of the nursing process.

Evaluation of data to determine effective action is part of the nursing process.

TJC JCAHO is a nonprofit organization that accredits health-care facilities and works to improve client care and safety.

5. While caring for a client, a nurse administers an incorrect dose of medication, causing the client to become ill. The nurse reports the incident to the nurse manager on the unit. The nurse manager then notifies risk management. Which risk-management strategies should be used by the nurse in this situation?

(Select all that apply.)

A. Documentation B. Physical assessment C. Unusual occurrence reports D. Professional liability insurance E. Systemic analysis of serious adverse events ANS: A, C, D, E Page: 29, 36

A. B. C. D. E.

Feedback A complete written account of care given to the client is a risk-management strategy.

Physical assessment is not considered a risk-management strategy.

Written unusual occurrence reports are a risk-management strategy.

Professional liability insurance to protect the nurse is a risk-management strategy.

Systemic analysis of serious adverse events is a risk-management strategy.

6. When nurses provide care to clients, nursing actions are governed by established standards of nursing care, as well as both state and federal laws. Which are sources of law? (Select all that apply.)

A. Constitution B. Statutes C. State Nurse Practice Acts D. Joint Commission standards E. Centers for Disease (CDC) standards.

ANS: A, B, C Page: 27, 29 Feedback

A. B. C. D. E.

The constitution provides laws that govern nursing practice.

Statutes provide laws that govern nursing practice.

State Nurse Practice Acts provide laws that govern nursing practice.

The Joint Commission, along with the American Nurses Association and specialty organizations, establishes standards of nursing care.

The Centers for Disease (CDC) in conjunction with the American Nurses Association and specialty organizations, establishes guidelines and standards of nursing care.

7. A The nursing supervisor of a new infusion clinic must conform to specific standards of practice when developing nursing policies and procedures for the new program. Which INS risk management strategies help decrease the risk of potential liability to the new clinic? (Select all that apply.)

A. Analysis of unusual occurrences B. Root cause analysis of sentinel events C. Evaluation of all patient data and surveys D. Comprehensive and thorough documentation E. Reduction of CLABSI related complications ANS: A, B, D Page: 16

A.

B.

C. D.

E.

Feedback Some examples of risk management strategies that may decrease the risk of potential liability to the organization or to the clinician include: Informed consent, analysis of unusual occurrence reports, systemic (root cause) analysis of serious adverse (sentinel) events, comprehensive and thorough documentation, and safe infusion medication administration.

Some examples of risk management strategies that may decrease the risk of potential liability to the organization or to the clinician include: Informed consent, analysis of unusual occurrence reports, systemic (root cause) analysis of serious adverse (sentinel) events, comprehensive and thorough documentation, and safe infusion medication administration.

Evaluation of all patient data and surveys is a process of patient experience data, not risk management strategies.

Some examples of risk management strategies that may decrease the risk of potential liability to the organization or to the clinician include: Informed consent, analysis of unusual occurrence reports, systemic (root cause) analysis of serious adverse (sentinel) events, comprehensive and thorough documentation, and safe infusion medication administration.

Reduction of CLABSI related complications is an outcome measure of valuebased purchasing and publicly reported outcomes.

8. While taking care of a client with multiple sclerosis, the infusion nurse inadvertently gives the client too much alemtuzumab by infusing longer than the recommended two hours. The nurse is proven negligent by which elements of the malpractice claim? (Select all that apply.)

A. The nurse has a duty to provide safe, effective treatment.

B. The nurse allows the client’s family to watch the infusion.

C. The client suffers difficulty breathing and chills during the infusion.

D. A breach of care occurs because the nurse administered too much medication.

E. The nurse should have offered the P.O. form of alemtuzumab.

ANS: A, C, D Page: 28–29

A. B. C. D.

E.

Feedback The nurse has a duty to the patient based on one of the four elements of a malpractice claim.

Allowing the family to watch the infusion is not a basis for a malpractice claim.

The patient has suffered actual harm or injury; this is one of the four elements of a malpractice claim.

The nurse failed to carry out the duty of providing safe, effective care by giving too much medication; a breach of care has occurred. This is one of the four elements of a malpractice claim.

Offering a P.O. form of any medication has to be ordered by the healthcare provider.

9. With in-depth knowledge of community resources, which skill will help the home care infusion nurse provide the best care? (Select all that apply.)

A. Meticulous evidence-based care B. Interprofessional communication and collaboration C. Appropriate parenteral nutrition and IV medication D. Ability to write home infusion therapy policy and procedures E. Safe, effective, and competent care ANS: A, B, E Page: 34–35

A. B. C. D.

Feedback The home care nurse must have a variety of well-developed skills which include providing meticulous evidence-based care Interprofessional communication and collaboration will help the nurse provide safe, effective care while utilizing community resources.

Appropriate parenteral nutrition and IV medication is important, but will not help the nurse with community resources.

The ability to write home infusion therapy policy and procedures is important,

E.

but will not aide the nurse with community resources.

The home care nurse with a variety of well-developed skills will provide safe, effective, and competent care.

10. A nurse fails to document that an injectable heparin has been given to a client for two weeks. Upon investigation it is determined that the heparin was not given and the nurse was reported to the state board of nursing. Which type of law is the state board using? (Select all that apply.)

A. Public law B. Administrative law C. Common law D. Constitutional law E. Statutory law ANS: A, B Page: 27

A. B.

C. D. E.

Feedback Public law is one of two main branches of law which is comprised of constitutional law and administrative law.

The state board of nursing is an example of administrative law which is empowered to revoke or annul a nurse’s license where there is evidence of incompetence, negligence, or fraud.

Common law is a court-made law where courts are responsible for interpreting the statutes.

Constitutional law is a formal set of rules and principles that describe the powers of a government and the rights of the people.

Statutory or legislative laws are formal laws written and enacted by federal, state, or local legislatures.

lOMoAR cPSD| 8660651

Chapter 1: Professional Practice Concepts for Infusion Therapy Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A nurse is attempting to initiate I.V. therapy for a client diagnosed with gastroenteritis. The client is combative and resists the nurse’s efforts to start the I.V. Which action by the nurse would result in an intentional tort?

A. Failing to document the client’s combativeness B. Refusing to wear gloves while starting the I.V. C. Failing to report the client’s combativeness to a physician D. Starting an I.V. on a coherent client against the client’s wishes

2. A nurse who is caring for clients understands that he or she should provide care that meets at least the minimum standards of practice for nursing. Which phrase regarding standards of practice is most accurate?

A. Standards of practice focus on the care provider and define needed activities and behaviors.

B. Standards of practice focus on the recipient of care and describe the outcomes of care.

C. Standards of practice are written laws enacted by the legislature.

D. Standards of practice are the result of the performance of a function or process.

3. Which incident would cause a nurse to be named as a defendant in a malpractice suit?

A. The nurse notes blood return noted in a peripheral IV catheter line.

B. The nurse reports early signs of infection from a peripheral line inserted by a nurse on another unit C. The nurse places two peripheral IV catheters in a patient requiring emergency IV fluids, but only uses one D. The nurse records nerve damage caused by a peripheral IV catheter inserted the previous shift nurse 4. The intravenous route is the most commonly used infusion route. The nurse notes that a client diagnosed with metastatic cancer is receiving an intraosseous infusion. Should the nurse question the healthcare pro- vider’s order?

A. Yes; the healthcare provider is not following INS recommendations.

B. No; the nurse should never question the healthcare provider’s order when it comes to chemother- apy.

C. Yes; this route of infusion is dangerous and not accepted by the INS. D. No; other routes might be appropriate for administration in certain situations and with selected fluids and medications.

P a g e 2 | 132

lOMoAR cPSD| 8660651

5. Which competency assessment method is acceptable for nursing competencies which will occur once per year in the skilled nursing facility?

A. Client Evaluation B. Clinical Data C. Sentinel Event Report D. Skills Checklist 6. One of the primary values of the INS designation of CRNI (certified registered nurse, infusion) is to: A. Protect the public B. Attain competence C. Reflect a measurable goal D. Hold nurses accountable 7. Which problem-solving approach to clinical practice is the nurse manager applying when determining patient preference and values for successful clinical outcomes?

A. Effective health-care practice B. Evidence-based practice (EBP) C. Answering a burning clinical question D. One’s own clinical expertise 8. Seven days ago the PICC nurse inserted a PICC line into the right forearm of a client diagnosed with cancer. When the nurse checks the client's site today, which nursing process outcome is determined?

A. Evaluating cancer treatment B. Implementing asepsis maintenance C. Planning for complication prevention D. Discussing prior cancer therapy 9. Which compensatory model has been applied if the hospitalization rate for CLABSIs (central lineassociated bloodstream infections) decreased significantly over the last quarter?

A. VBP B. HHRP C. HAC D. HHVBP 10. When called as an expert witness in an upcoming case, the nurse manager employs which techniques?

A. Examines evidence and give advice B. Reviews charts and assesses jury selection C. Gives deposition and notifies lawyers of discrepancies D. Testifies and establishes standards of care P a g e 3 | 132

lOMoAR cPSD| 8660651

Multiple Response Identify one or more choices that best complete the statement or answer the question.

1. A nurse is caring for multiple clients in a rehabilitation facility. During the shift, the nurse notes that several clients are on high-risk medications. According to the Risk Evaluation and Mitigation Strategy (REMS) program, when can the U.S. Food and Drug Administration (FDA) require a REMS? (Se- lect all that apply.)

A. Before FDA drug approval B. After FDA drug approval C. During a client evaluation D. At an ethics committee meeting E. After client informed consent 2. A new infusion clinic is being started. The nursing supervisor of the new clinic must conform to specific standards of practice when developing nursing policies and procedures for the new program.

To which organizational standards of practice must the nurse manager adhere? (Select all that apply.)

A. Centers for Disease Control and Prevention (CDC) guidelines B. Infusion Nurses Society (INS) standards C. American Medical Association (AMA) standards D. Oncology Nursing Society (ONS) standards E. U.S. Food and Drug Administration (FDA) 3. A staff nurse is serving on a hospital’s quality-assurance improvement task force. On which quality- assurance improvement models is the task force most likely to focus? (Select all that apply.)

A. Standards of care B. Standards of practice C. Performance improvement D. Continuous quality improvement E. Total Quality Management (TQM) 4. Which methods should the nurse use to evaluate achievement of client outcomes prior to discharge?

(Select all that apply.)

A. B. C. D. E.

Collect data to determine whether standards were met.

Identify controllable or uncontrollable variables.

Determine the cause of the problem by comparing actual care with established standards.

Re-evaluate to determine whether corrective action is effective and improvement in service is obtained.

Contact The Joint Commission (JCAHO) Web site for standards.

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5. While caring for a client, a nurse administers an incorrect dose of medication, causing the client to become ill. The nurse reports the incident to the nurse manager on the unit. The nurse manager then notifies risk management. Which risk-management strategies should be used by the nurse in this situation? (Select all that apply.)

A. Documentation B. Physical assessment C. Unusual occurrence reports D. Professional liability insurance E. Systemic analysis of serious adverse events

6. When nurses provide care to clients, nursing actions are governed by established standards of nursing care, as well as both state and federal laws. Which are sources of law? (Select all that apply.)

A. Constitution B. Statutes C. State Nurse Practice Acts D. Joint Commission standards E. Centers for Disease (CDC) standards.

7. The nursing supervisor of a new infusion clinic must conform to specific standards of practice when developing nursing policies and procedures for the new program. Which INS risk management strat- egies help decrease the risk of potential liability to the new clinic? (Select all that apply.)

A. Analysis of unusual occurrences B. Root cause analysis of sentinel events C. Evaluation of all patient data and surveys D. Comprehensive and thorough documentation E. Reduction of CLABSI related complications 8. While taking care of a client with multiple sclerosis, the infusion nurse inadvertently gives the client too much alemtuzumab by infusing longer than the recommended two hours. The nurse is proven negli- gent by which elements of the malpractice claim? (Select all that apply.)

A. The nurse has a duty to provide safe, effective treatment.

B. The nurse allows the client’s family to watch the infusion.

C. The client suffers difficulty breathing and chills during the infusion.

D. A breach of care occurs because the nurse administered too much medication.

E. The nurse should have offered the P.O. form of alemtuzumab.

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the best care? (Select all that apply.)

A. Meticulous evidence-based care B. Interprofessional communication and collaboration C. Appropriate parenteral nutrition and IV medication D. Ability to write home infusion therapy policy and procedures E. Safe, effective, and competent care 10. A nurse fails to document that an injectable heparin has been given to a client for two weeks. Upon investigation it is determined that the heparin was not given and the nurse was reported to the state board of nursing. Which type of law is the state board using? (Select all that apply.)

A. Public law B. Administrative law C. Common law D. Constitutional law E. Statutory law

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Chapter 1: Professional Practice Concepts for Infusion Therapy Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A nurse is attempting to initiate I.V. therapy for a client diagnosed with gastroenteritis. The client is combative and resists the nurse’s efforts to start the I.V. Which action by the nurse would result in an intentional tort?

A. Failing to document the client’s combativeness B. Refusing to wear gloves while starting the I.V. C. Failing to report the client’s combativeness to a physician D. Starting an I.V. on a coherent client against the client’s wishes ANS: D Page: 28 A. B. C. D.

Feedback Failure to document does not result in direct injury or harm to a client and is, therefore, not an intentional tort.

Refusing to wear gloves may inadvertently result in injury or harm, but is not considered an intentional tort.

Failure to report the behavior to a physician does not result in direct injury or harm to the client and is not considered an intentional tort.

Intentional torts include assault and battery, false imprisonment, using restraints as a form of false imprisonment, defamation of character, and breach of confi- dentiality.

2. A nurse who is caring for clients understands that he or she should provide care that meets at least the minimum standards of practice for nursing. Which phrase regarding standards of practice is most accurate?

A. Standards of practice focus on the care provider and define needed activities and behaviors.

B. Standards of practice focus on the recipient of care and describe the outcomes of care.

C. Standards of practice are written laws enacted by the legislature.

D. Standards of practice are the result of the performance of a function or process.

ANS: A Page: 16 A.

Feedback Standards of practice are criteria for measuring performance against the optimal achievable degree of clinical excellence. These standards are formulated to communicate expectations of nursing practice. Agencies are influential in devel- oping standards of practice.

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C. D.

Standards of practice are evidence-based guidelines, policies, or protocols not written laws.

Standards of practice may occur in response to unanswered questions, limited research, and/or performance issues; not necessarily the result of the perfor- mance or process.

3. Which incident would cause a nurse to be named as a defendant in a malpractice suit?

A. The nurse notes blood return noted in a peripheral IV catheter line.

B. The nurse reports early signs of infection from a peripheral line inserted by a nurse on another unit C. The nurse places two peripheral IV catheters in a patient requiring emergency IV fluids, but only uses one D. The nurse records nerve damage caused by a peripheral IV catheter inserted the previous shift nurse ANS: D Page: 29 A. B. C. D.

Feedback Blood return at the catheter site is normal.

Reporting early signs of infection is expected.

Using one peripheral IV catheter may be warranted.

The nurse had a duty to do no harm to the client and the client suffered actual harm or injury.

4. The intravenous route is the most commonly used infusion route. The nurse notes that a client diagnosed with metastatic cancer is receiving an intraosseous infusion. Should the nurse question the healthcare pro- vider’s order?

A. Yes; the healthcare provider is not following INS recommendations.

B. No; the nurse should never question the healthcare provider’s order when it comes to chemother- apy.

C. Yes; this route of infusion is dangerous and not accepted by the INS. D. No; other routes might be appropriate for administration in certain situations and with selected fluids and medications.

ANS: D Page: 3 A. B.

Feedback Infusion Nurses Society (INS) Standards, infusion therapy is provided with attention to safety and quality with individualized care that is collaborative, cultur- ally sensitive, and age appropriate.

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C.

D.

enough to ask the healthcare provider and evidence-based criteria should be the basis for practice answers.

This is an acceptable router per INS standards. There are risks, some complica- tions are serious and even life-threatening, and many complications are prevent- able with sound nursing care. The nurse must have a thorough understanding and knowledge of the type of access device being utilized, potential complications of infusion solutions, and safe infusion administration.

The intravenous (I.V.) route is the most commonly used infusion route; however, other infusion routes include intraosseous, subcutaneous, and intraspinal. In this case, the intraosseous route might be appropriate for administration with the se- lected fluids and medications.

5. Which competency assessment method is acceptable for nursing competencies which will occur once per year in the skilled nursing facility?

A. Client Evaluation B. Clinical Data C. Sentinel Event Report D. Skills Checklist ANS: D Page: 4 A. B. C. D.

Feedback Client evaluation is concern that may drive competency validation, but is not a method of competency assessment.

Clinical data is based on outcome criteria that drives competency validation, but is not a method of competency assessment.

Sentinel event reports are another form of competency validation, but they are not methods of competency assessment.

Competency assessment methods include performance measures related to patient care, such as skills, knowledge, ability, and judgement that includes objec- tive, measureable assessment of the actual performance in the form of checklists.

6. One of the primary values of the INS designation of CRNI (certified registered nurse, infusion) is to: A. Protect the public B. Attain competence C. Reflect a measurable goal D. Hold nurses accountable ANS: A Page: 6 A.

Feedback Certification is a mark of excellence, validates nursing knowledge and skills, P a g e 11 | 132

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B.

and protects the public.

An INS Standard is that the clinician is responsible and accountable for attaining

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C. D.

and maintaining competence with infusion therapy administration and venous access device insertion/management.

Competency statements need to reflect a measurable goal.

All professional nurses are accountable and responsible for all parts of the tasks associated with infusion therapy.

7. Which problem-solving approach to clinical practice is the nurse manager applying when determining patient preference and values for successful clinical outcomes?

A. Effective health-care practice B. Evidence-based practice (EBP) C. Answering a burning clinical question D. One’s own clinical expertise ANS: B Page: 7 A. B. C. D.

Feedback Effective health-care practice is an essential characteristic of evidencebased practice.

EBP is a problem-solving approach to clinical practice and administrative issues that integrates patient preference and values.

EBP is a systematic search for and critical appraisal of the most relevant evi- dence to answer a burning clinical question.

EBP is a problem-solving approach that integrates one’s own clinical expertise.

8. Seven days ago the PICC nurse inserted a PICC line into the right forearm of a client diagnosed with cancer. When the nurse checks the client's site today, which nursing process outcome is determined?

A. Evaluating cancer treatment B. Implementing asepsis maintenance C. Planning for complication prevention D. Discussing prior cancer therapy ANS: A Page: 13 A.

B. C. D.

Feedback As the cancer treatment begins, the evaluation phase begins. The plan of care should be based on the conclusion that the outcome has not been met at this time.

Maintenance of asepsis is the implementation or action plan of the nursing pro- cess.

Planning utilizes techniques to prevent complications Discussion of prior cancer therapy is a subjective assessment.

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bloodstream infections) decreased significantly over the last quarter?

A. VBP B. HHRP C. HAC D. HHVBP ANS: C Page: 18 A. B. C. D.

Feedback Value-based purchasing (VBP) is a pay-for-performance program mandated by the Affordable Care Act (ACA).

Hospital readmissions reduction program (HRRP) is a pay-for-performance pro- gram mandated by the Affordable Care Act (ACA).

Hospital-acquired conditions (HAC) pay-for-performance program mandated by the Affordable Care Act (ACA). CLABSIs are hospital acquired.

Home health value-based purchasing is a model pay-for-performance program implemented for home health.

10. When called as an expert witness in an upcoming case, the nurse manager employs which techniques?

A. Examines evidence and give advice B. Reviews charts and assesses jury selection C. Gives deposition and notifies lawyers of discrepancies D. Testifies and establishes standards of care ANS: A Page: 30 A. B. C. D.

Feedback Serving as an expert witness involves examining evidence, reviewing nursing literature, giving depositions, and testifying in court.

Reviewing charts and assessing jury selection are not functions of an expert wit- ness.

Expert witnesses do not notify lawyers of discrepancies.

Establishing standards of care is not a function of an expert witness.

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Multiple Response Identify one or more choices that best complete the statement or answer the question.

1. A nurse is caring for multiple clients in a rehabilitation facility. During the shift, the nurse notes that several clients are on high-risk medications. According to the Risk Evaluation and Mitigation Strategy (REMS) program, when can the U.S. Food and Drug Administration (FDA) require a REMS? (Se- lect all that apply.)

A. Before FDA drug approval B. After FDA drug approval C. During a client evaluation D. At an ethics committee meeting E. After client informed consent ANS: A, B Page: 19 A. B. C. D. E.

Feedback Before approval of the drug if the FDA determines a REMS is necessary to en- sure that the benefits of the drug outweigh the risks.

Postapproval if the FDA becomes aware of new safety information and determines that a REMS is necessary to ensure that the benefits of the drug outweigh the risks.

The FDA does not require a REMS during a client evaluation.

The FDA does not require a REMS at an ethics committee meeting.

The FDA does not require a REMS after client informed consent.

2. A new infusion clinic is being started. The nursing supervisor of the new clinic must conform to specific standards of practice when developing nursing policies and procedures for the new program.

To which organizational standards of practice must the nurse manager adhere? (Select all that apply.)

A. Centers for Disease Control and Prevention (CDC) guidelines B. Infusion Nurses Society (INS) standards C. American Medical Association (AMA) standards D. Oncology Nursing Society (ONS) standards E. U.S. Food and Drug Administration (FDA)

ANS: A, B, D Page: 6, 9, 16 A. B. C.

Feedback The nurse manager must adhere to the guidelines of the CDC. The nurse manager must adhere to the guidelines of the INS. The AMA does not provide guidelines for nursing standards of practice.

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D. E.

The nurse manager must adhere to the guidelines of the ONS. The FDA does not provide guidelines for nursing standards of

3. A staff nurse is serving on a hospital’s quality-assurance improvement task force. On which quality- assurance improvement models is the task force most likely to focus? (Select all that apply.)

A. Standards of care B. Standards of practice C. Performance improvement D. Continuous quality improvement E. Total Quality Management (TQM) ANS: B, C, D, E Page: 15–17 A. B. C. D. E.

Feedback Standards of practice care focus on the provider, and define the activities and behaviors needed to achieve patient outcomes.

The task force is most likely to focus on Standards of practice. This as a quality- assurance model focuses on the recipient of care.

The task force is most likely to focus on Performance improvement. This quality-assurance model focuses on the recipient of care as a quality-assurance model.

The task force is most likely to focus on Continuous quality improvement . This quality-assurance model focuses on the recipient of care.

Total quality management (TQM) is a quality-assurance model that focuses on maximizing customer satisfaction.

4. Which methods should the nurse use to evaluate achievement of client outcomes prior to discharge?

(Select all that apply.)

A. B. C. D. E.

Collect data to determine whether standards were met.

Identify controllable or uncontrollable variables.

Determine the cause of the problem by comparing actual care with established standards.

Re-evaluate to determine whether corrective action is effective and improvement in service is obtained.

Contact The Joint Commission (JCAHO) Web site for standards.

ANS: A, B, C, D Page: 36 Feedback P a g e 17 | 132

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A. B.

Collection is part of the nursing process.

Identification is part of the nursing process.

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C. D. E.

Determination of the cause of the problem is part of the nursing process.

Evaluation of data to determine effective action is part of the nursing process.

TJC JCAHO is a nonprofit organization that accredits health-care facilities and works to improve client care and safety.

5. While caring for a client, a nurse administers an incorrect dose of medication, causing the client to become ill. The nurse reports the incident to the nurse manager on the unit. The nurse manager then notifies risk management. Which risk-management strategies should be used by the nurse in this situation? (Select all that apply.)

A. Documentation B. Physical assessment C. Unusual occurrence reports D. Professional liability insurance E. Systemic analysis of serious adverse events ANS: A, C, D, E Page: 29, 36 A. B. C. D. E.

Feedback A complete written account of care given to the client is a riskmanagement strategy.

Physical assessment is not considered a risk-management strategy.

Written unusual occurrence reports are a risk-management strategy.

Professional liability insurance to protect the nurse is a risk-management strategy.

Systemic analysis of serious adverse events is a risk-management strategy.

6. When nurses provide care to clients, nursing actions are governed by established standards of nursing care, as well as both state and federal laws. Which are sources of law? (Select all that apply.)

A. Constitution B. Statutes C. State Nurse Practice Acts D. Joint Commission standards E. Centers for Disease (CDC) standards.

ANS: A, B, C Page: 27, 29 Feedback P a g e 19 | 132

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B. C. D. E.

Statutes provide laws that govern nursing practice.

State Nurse Practice Acts provide laws that govern nursing practice.

The Joint Commission, along with the American Nurses Association and specialty organizations, establishes standards of nursing care.

The Centers for Disease (CDC) in conjunction with the American Nurses Association and specialty organizations, establishes guidelines and standards of nurs- ing care.

7. A The nursing supervisor of a new infusion clinic must conform to specific standards of practice when developing nursing policies and procedures for the new program. Which INS risk management strat- egies help decrease the risk of potential liability to the new clinic? (Select all that apply.)

A. Analysis of unusual occurrences B. Root cause analysis of sentinel events C. Evaluation of all patient data and surveys D. Comprehensive and thorough documentation E. Reduction of CLABSI related complications ANS: A, B, D Page: 16 A.

B.

C. D.

E.

Feedback Some examples of risk management strategies that may decrease the risk of po- tential liability to the organization or to the clinician include: Informed consent, analysis of unusual occurrence reports, systemic (root cause) analysis of serious adverse (sentinel) events, comprehensive and thorough documentation, and safe infusion medication administration.

Some examples of risk management strategies that may decrease the risk of po- tential liability to the organization or to the clinician include: Informed consent, analysis of unusual occurrence reports, systemic (root cause) analysis of serious adverse (sentinel) events, comprehensive and thorough documentation, and safe infusion medication administration.

Evaluation of all patient data and surveys is a process of patient experience data, not risk management strategies.

Some examples of risk management strategies that may decrease the risk of po- tential liability to the organization or to the clinician include: Informed consent, analysis of unusual occurrence reports, systemic (root cause) analysis of serious adverse (sentinel) events, comprehensive and thorough documentation, and safe infusion medication administration.

Reduction of CLABSI related complications is an outcome measure of value- based purchasing and publicly reported outcomes.

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8. While taking care of a client with multiple sclerosis, the infusion nurse inadvertently gives the client too much alemtuzumab by infusing longer than the recommended two hours. The nurse is proven negli- gent by which elements of the malpractice claim? (Select all that apply.)

A. The nurse has a duty to provide safe, effective treatment.

B. The nurse allows the client’s family to watch the infusion.

C. The client suffers difficulty breathing and chills during the infusion.

D. A breach of care occurs because the nurse administered too much medication.

E. The nurse should have offered the P.O. form of alemtuzumab.

ANS: A, C, D Page: 28–29 A. B. C. D. E.

Feedback The nurse has a duty to the patient based on one of the four elements of a mal- practice claim.

Allowing the family to watch the infusion is not a basis for a malpractice claim.

The patient has suffered actual harm or injury; this is one of the four elements of a malpractice claim.

The nurse failed to carry out the duty of providing safe, effective care by giving too much medication; a breach of care has occurred. This is one of the four ele- ments of a malpractice claim.

Offering a P.O. form of any medication has to be ordered by the healthcare pro- vider.

9. With in-depth knowledge of community resources, which skill will help the home care infusion nurse provide the best care? (Select all that apply.)

A. Meticulous evidence-based care B. Interprofessional communication and collaboration C. Appropriate parenteral nutrition and IV medication D. Ability to write home infusion therapy policy and procedures E. Safe, effective, and competent care ANS: A, B, E Page: 34–35 A. B. C. D.

Feedback The home care nurse must have a variety of well-developed skills which include providing meticulous evidence-based care Interprofessional communication and collaboration will help the nurse provide safe, effective care while utilizing community resources.

Appropriate parenteral nutrition and IV medication is important, but will not help the nurse with community resources.

The ability to write home infusion therapy policy and procedures is important, but will not aide the nurse with community resources.

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E.

The home care nurse with a variety of well-developed skills will provide safe, effective, and competent care.

10. A nurse fails to document that an injectable heparin has been given to a client for two weeks. Upon investigation it is determined that the heparin was not given and the nurse was reported to the state board of nursing. Which type of law is the state board using? (Select all that apply.)

A. Public law B. Administrative law C. Common law D. Constitutional law E. Statutory law ANS: A, B Page: 27 A. B.

C. D. E.

Feedback Public law is one of two main branches of law which is comprised of constitu- tional law and administrative law.

The state board of nursing is an example of administrative law which is empow- ered to revoke or annul a nurse’s license where there is evidence of incompetence, negligence, or fraud.

Common law is a court-made law where courts are responsible for interpreting the statutes.

Constitutional law is a formal set of rules and principles that describe the powers of a government and the rights of the people.

Statutory or legislative laws are formal laws written and enacted by federal, state, or local legislatures.

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Chapter 2: Infection Prevention and Occupational Risks Multiple Choice Identify the choice that best completes the statement or answers the question.

1. During a hospital orientation, a newly hired nurse learns that infectious waste must be incinerated as mandated by the Environmental Protection Agency (EPA). The nurse understands that the main focus of the EPA is on: a. risk-assessment strategies. b. performance-improvement strategies. c. quality management. d. occupational safety.

2. A healthy individual comes in contact with a rhinovirus while out in the community. Which actions constitute the first line of nonspecific defense mechanisms against the invading infection? a. Phagocytosis and a complement cascade b. Leukocytes and proteins c. Physical and chemical barriers d. Immune system and phagocytes 3. A nurse is teaching a client who is immunosuppressed about ways to help the client to avoid infections. The nurse teaches the client that the purpose of the immune system is to provide: a. the body with antigens. b. a way to inhibit the formation of antibodies to antigens. c. a way for the organism to move from the source to the host. d. the body with a way to recognize and destroy invading antigens.

4. A nurse is caring for a hospitalized client who has a health-care–associated infection. The nurse understands that the links in the chain of infection consist of: a. organism, inflammation, and infection. b. disease, the organism, and the host. c. agent, the host, and transmission. d. host, signs, and symptoms.

5. A hospitalized client has acquired an infusion-related infection. Which is the most appropriate intervention for a nurse to implement when caring for a client who has an infusion-related infection? a. Monitoring for signs and symptoms of sepsis b. Monitoring for dysrhythmias c. Use of full-barrier protection d. Educating the client on good hand hygiene techniques 6. A client with active tuberculosis (TB) is admitted to a hospital. A nurse implements transmissionbased precautions when caring for the client because the nurse is concerned about the dissemination of the disease. Which statement best describes dissemination? a. The movement of an organism from source to the host P a g e 24 | 132

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b. Produced within or caused by factors within the organism c. The replication of organisms in the tissue of the host d. The movement of microorganisms from an individual into the immediate

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environment 7. A nurse on an intensive care unit is caring for a febrile client with a central venous catheter whose blood pressure is steadily dropping. The nurse suspects septicemia. Which microorganism is responsible for most cases of septicemia related to infusion? a. Mycobacterium b. Yersinia c. Coagulase-negative staphylococci d. Salmonella Multiple Response Identify one or more choices that best complete the statement or answer the question.

1. A nurse teaches a client newly diagnosed with HIV about the immune system. Which organs should the nurse include when discussing the client’s immune system? SELECT ALL THAT APPLY. a. Thymus b. Bone marrow c. Heart d. Lungs 2. A new client diagnosed with AIDS is being seen in a hospital clinic. Which characteristics should a nurse anticipate when assessing a client with immunosuppression? SELECT ALL THAT APPLY. a. Frequent infections b. Infections that are more severe than usual c. Incomplete response to treatment d. Leukocyte count of 5,000 to 10,000 3. A nurse is caring for a client who has an I.V. access. With which sources of contamination should the nurse be concerned when attempting to reduce the client’s risk of infection? SELECT ALL THAT APPLY. a. Skin b. Air c. Entry ports d. Mucous membranes 4. A nurse is preparing to initiate I.V. therapy on a client admitted with dehydration. Which precannulation antiseptic agents are acceptable for the nurse to use, according to the Infusion Nurses Society’s Standards of Practice, to cleanse the client’s skin? SELECT ALL THAT APPLY. a. 70% isopropyl alcohol b. Povidone-iodine c. 2% chlorhexidine gluconate d. Hydrogen peroxide 5. A new client, diagnosed with AIDS, is being seen in a hospital clinic. Which characteristics should a nurse anticipate when taking the health history of a client with immunosuppression? SELECT ALL THAT APPLY. a. Frequent infections b. Infections that are more severe than usual P a g e 26 | 132

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c. Incomplete response to treatment d. Infections that are usually from common sources 6. A nurse teaches a client, newly diagnosed with HIV, about the immune system. Which organs should the nurse include when discussing the client’s immune system? SELECT ALL THAT APPLY. a. Thymus b. Bone marrow c. Heart d. Lungs 7. A physician writes an order for a nurse to begin administering I.V. fluids to a client diagnosed with hepatitis A. While implementing this order, to which occupational risks is the nurse exposed?

SELECT ALL THAT APPLY. a. Latex allergy b. Chemical exposure c. Needlestick injuries d. Back injury 8. A nurse is preparing to administer I.V. chemotherapy for a client diagnosed with cancer. Which are potential occupational risks associated with I.V. therapy? SELECT ALL THAT APPLY. a. Falls b. Latex allergy c. Chemical exposure d. Needlestick injuries 9. A home-care nurse provides education regarding basic infection control to the parents of a child with HIV infection. Which instructions should be included in the nurse’s education? SELECT ALL THAT APPLY. a. Carefully wash all fresh fruits and vegetables. b. Wash bottles, nipples, and pacifiers in the dishwasher. c. Immediately discard any unused food and formula. d. Cleanse the inside of the nipple of the bottle with salt and rinse well if it becomes slimy.

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Chapter 2: Infection Prevention and Occupational Risks Answer Section MULTIPLE CHOICE 1. ANS: A The EPA is one agency that performs risk assessment. Risk assessment takes different approaches depending on what information is available. Some assessments look back to try to assess effects after an event. Other assessments look forward to anticipate effects before a new product is approved for use.

Reference: U.S. Environmental Protection Agency. (2009). Hospital/medical/infectious waste incinerators. Retrieved from www.epa.gov/ttn/atw/129/hmiwi/rihmiwi.html, March 10, 2013.

PTS: 1 KEY: Cognitive Level: Application 2. ANS: C The first lines of defense for healthy human hosts, to protect themselves from environmental microbes, are the physical (skin, mucous membrane, epiglottis, respiratory tract cilia, and sphincter) and chemical barriers (tears, gastric acidity, and vaginal secretions). Mechanical barriers also provide a line of defense.

PTS: 1 KEY: Cognitive Level: Application 3. ANS: D Appropriate immune response occurs when the immune system recognizes and destroys invading antigens.

PTS: 1 KEY: Cognitive Level: Application 4. ANS: C The nurse understands that the client’s infection results from interaction between an infectious agent and a susceptible host. This interaction, called transmission, occurs by means of contact between the agent and the host. Three interrelated factors—the agent, the host, and transmission—represent the chain of infection.

Reference: Siegel, J. D., Rhinehart, E., Jackson, M., et al. (2007). Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Retrieved from www.cdc.gov/ncidod/dhq/pdf/isolation2007.pdf PTS: 1 KEY: Cognitive Level: Application 5. ANS: A Sepsis is a serious complication of infusion therapy. Signs and symptoms, such as fluctuating fever, profuse sweating, nausea and vomiting, abdominal pain, tachycardia, and hypotension, should be reported immediately to the physician.

PTS: 1 KEY: Cognitive Level: Application 6. ANS: D Dissemination is a shedding of microorganisms. Cultures of air samples, surfaces, and objects reveal dissemination or shedding of microorganisms.

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7. ANS: C Infusion-related septicemia and fungemia are more likely than cannula-related infections to culminate in frank shock and are often unrecognized. Most infusion-related septicemia is by gram- negative bacilli introduced by intrinsic or extrinsic contamination. Yersinia and Salmonella can occur in contaminated blood products, and Mycobacterium has been found in infections related to central venous catheters.

PTS: 1

KEY: Cognitive Level: Application

MULTIPLE RESPONSE 1. ANS: A, B, D The nurse should include the thymus, bone marrow, and lungs when teaching the client about his or her immune system. The thymus and bone marrow are primary organs of the immune system. The lungs are a secondary organ of the immune system. The heart does not contribute to the immune response.

PTS: 1 KEY: Cognitive Level: Application 2. ANS: A, B, C The nurse should anticipate that the client experiences frequent infections, has infections that are more severe than usual, and usually has an incomplete response to therapy. The normal white cell count is 5,000 to 10,000. The nurse should expect to see an increased white cell count in an immunocompromised client with an infection.

PTS: 1 KEY: Cognitive Level: Application 3. ANS: A, B, C Microorganisms gain entry via the skin, via air entering into the closed system, and via entry points into the administration set, such as the junction between the administration set and the catheter hub. Mucous membranes would not be a source of contamination during I.V. therapy.

Reference: O’Grady, N. P., Alexander, M., Burns, L. A., et al; Healthcare Practices Advisory Committee. (2011). Guidelines for prevention of intravascular catheter related infections, 2011. American Journal of Infection Control, 39(4 Suppl.), S1–S34.

PTS: 1 KEY: Cognitive Level: Knowledge 4. ANS: A, B, C Cleansing the insertion site reduces the potential for infection by minimizing the amount of microorganisms on the skin. The Centers for Disease Control and Prevention (2009) now recommends 2% chlorhexidine gluconate as the solution of choice for infusion therapy preparation. Reference: O’Grady, N. P., Alexander, M., Burns, L. A., et al; Healthcare Practices Advisory Committee. (2011). Guidelines for prevention of intravascular catheter related infections, 2011.

American Journal of Infection Control, 39(4 Suppl.), S1–S34.

PTS: 1 5. ANS: A, B, C

KEY: Cognitive Level: Application

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The nurse should anticipate a history of frequent infections, infections that are more severe than usual, and incomplete response to treatments. These clients often present with unusual infections or infections with opportunistic infectious agents.

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Reference: Phillips, L. D., & Gorski, L. (2014). Infusion-related infection control and occupational risks. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 6. ANS: A, B, D The nurse should discuss the thymus, bone marrow, and lungs when teaching the client about his or her immune system. The organs and cells involved in the immune system form a complex when antigens and immune system cells are constantly moving through the lymphatic system and organs and blood circulation. The heart is not an organ directly responsible for immune function. Both the thymus and bone marrow are primary immune organs, whereas the lungs are secondary immune organs.

Reference: Phillips, L. D., & Gorski, L. (2014). Infusion-related infection control and occupational risks. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 7. ANS: A, B, C Latex allergy, chemical exposure, and needlestick injuries are directly related to the initiation of infusion therapy. Back injuries are associated with lifting and moving clients and with poor body mechanics.

Reference: Phillips, L. D., & Gorski, L. (2014). Infusion-related infection control and occupational risks. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 8. ANS: B, C, D The nurse providing infusion therapy is at risk for latex and chemical exposure in the process of delivering infusion therapy. Needlestick injury risk is highest with the hollow-bore needles, such as with over-the-needle catheters. Falls are a risk for clients.

Reference: Phillips, L. D., & Gorski, L. (2014). Infusion-related infection control and occupational risks. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 9. ANS: A, B, D The parents should be instructed to carefully wash all fruits and vegetables; wash bottles, nipples, and pacifiers in the dishwasher; and cleanse the inside of the bottle nipple with salt if it becomes slimy. The parents should also be instructed to cover and refrigerate unused food and formula, and to discard unused refrigerated food or formula after 24 hours.

Reference: Phillips, L. D., & Gorski, L. (2014). Infusion-related infection control and occupational risks. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

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Chapter 3: Fundamentals of Fluid and Electrolyte Balance Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A nurse is assessing an older adult client who is disoriented to time and place. The nurse notes that the client’s eyes are sunken, the mouth is coated, the tongue has an extra longitudinal furrow, and the client’s lips are cracked. The client’s hand vein filling takes more than 5 seconds; tenting is apparent over the sternum; and the vital signs are BP 110/60 mm Hg, pulse 62, and respiratory rate of 12.

Based on these assessment findings, which fluid or electrolyte imbalance should the nurse suspect? a. Sodium excess b. Magnesium deficit c. Fluid volume deficit d. Fluid volume excess 2. A nurse prepares to assess a client who has been vomiting for several days. For which signs of fluid volume deficit (FVD) should the nurse assess? a. Bounding pulse, decreased blood pressure, and moist crackles b. Dyspnea, jugular vein distention, and sternum fingerprinting c. Increased pulse rate, decreased blood pressure, and poor skin turgor d. Increased respiratory rate; warm, moist skin; and decreased body temperature 3. A nurse assesses a client who has moist crackles (rales) in the lung bases, an increased respiratory rate, dyspnea, and 3+ edema of the ankles. Which is the most accurate nursing diagnosis for this client? a. Fluid volume deficit b. Fluid volume excess c. Impaired tissue integrity d. Altered tissue perfusion, renal 4. A nurse analyzes a client’s laboratory report that shows a serum potassium level of 5.7 mEq/L. Which client’s laboratory report is the nurse most likely reviewing? a. The client with ulcerative colitis b. The client with Cushing’s syndrome c. The client who has overused laxatives d. The client who has sustained a traumatic burn 5. A nurse notes that a client admitted with renal failure has a serum phosphorus level of 7.0 mg/dL. Which medication should a nurse expect to be prescribed for this client? a. Calcium gluconate b. Calcium chloride c. Calcitonin (Calcimar) d. Aluminum hydroxide gel (Amphojel) 6. A nurse is caring for a client with an ileostomy. Which acid-base imbalance will this client most likely experience? a. Metabolic alkalosis P a g e 33 | 132

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c. Respiratory acidosis d. Respiratory alkalosis 7. A nurse assesses a newly admitted client and notes fatigued muscles, reports of nausea and anorexia, irritability, and diminished deep tendon reflexes. The nurse reviews the client’s laboratory reports that reveal a serum chloride level of 92 mEq/L, a serum potassium level of 3.1 mEq/L, and a serum sodium level of 135 mEq/L. Which treatment should the nurse anticipate for this electrolyte imbalance? a. Treatment with sodium bicarbonate b. Change of infusion to 5% dextrose in water c. Replacement therapy with potassium chloride d. Replacement therapy with sodium and chloride 8. A pediatric nurse is thinking critically to determine the best methods for assessing an infant’s 24hour fluid needs. Which three methods for assessment of 24-hour fluid needs in an infant should the nurse consider? a. Meter square, diaper weight, and urinary output b. Meter square, body weight, and caloric methods c. Meter square, specific gravity of urine, and urinary output d. Diaper weight, urinary output, and caloric needs 9. A nurse is administering I.V. potassium at a rate of 15 mEq/hr via a peripheral vein. When infusing potassium at this rate via this route, for which imbalance should the nurse monitor? a. Hypernatremia b. Hypercalcemia c. Hyperkalemia d. Hyperglycemia 10. A client in a critical-care unit is experiencing drastic fluctuations in serum potassium. Which sentinel event can occur if the client’s serum potassium level is less than 2.5 mEq/L or greater than 7.0 mEq/L? a. Embolic stroke b. Cardiac arrest c. Atrial fibrillation d. Intracranial hemorrhage 11. A nursing instructor is teaching a group of nursing students about the intracellular and extracellular fluid compartments of the cell. Which is the major electrolyte in the intracellular compartment? a. Calcium b. Sodium c. Potassium d. Bicarbonate 12. A nursing instructor is teaching a group of nursing students about the intracellular and extracellular fluid compartments of the cell. Which electrolyte is the second most plentiful cation in the intracellular fluid compartment? a. Calcium b. Sodium P a g e 35 | 132

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c. Chloride d. Magnesium 13. A nurse educator is conducting an in-service presentation on electrolytes. Which group of electrolytes should the educator refer to as being “positively charged”? a. Potassium, sodium, calcium b. Potassium, sodium, bicarbonate c. Bicarbonate, phosphate, chloride d. Chloride, magnesium, bicarbonate 14. A nurse is caring for a client who has been experiencing prolonged vomiting prior to being admitted to a hospital. The client has experienced development of metabolic alkalosis. Which of the following are manifestations of alkalosis (bicarbonate excess)? a. Tetany, soft tissue calcification b. Dizziness, tingling of fingers and toes, carpopedal spasm c. Kussmaul respirations, confusion, increased respiratory rate d. Impaired mentation, tingling of fingers and toes, depressed respirations 15. A nurse assesses a newly admitted client and notes fatigued muscles, reports of nausea and anorexia, irritability, and diminished deep tendon reflexes. The nurse reviews the client’s laboratory reports, which reveal a serum chloride level of 92 mEq/L, a serum potassium level of 3.1 mEq/L, and a serum sodium level of 135 mEq/L. Which electrolyte imbalance should the nurse suspect? a. Hyponatremia b. Hypokalemia c. Hyperchloremia d. Hypernatremia 16. A client presents to an emergency department with confusion, a respiratory rate of 30 breaths per minute, blood pressure 100/70 mm Hg, and a previous admission for renal failure. The client’s arterial blood gases reveal a pH of 7.32, an HCO3 of 20 mEq/L, and a PaCO2 of 34 mm Hg. Which acid-base imbalance should a nurse suspect? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis 17. An intensive care nurse is implementing orders for an elderly client diagnosed with hypermagnesemia. What is the most likely cause of hypermagnesemia in this client? a. Renal failure b. Nasogastric tubes to suction c. Use of mechanical ventilators d. Overzealous administration of I.V. potassium chloride 18. A nurse is caring for an elderly, hospitalized client diagnosed with emphysema. The client’s arterial blood gases reveal that the blood chemistry is slightly alkaline but is considered physiologically neutral. To be considered physiologically neutral, or normal, what is the client’s serum pH? P a g e 36 | 132

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c. 7.4 d. 7.5 19. Which nursing action would be most important after adding 20 mEq potassium chloride to an I.V. bag of 1000 mL of 5% dextrose in water? a. Rotate the bag gently. b. Attach the tubing to the client. c. Check the solution for particles. d. Place the time-tape on the I.V. bag.

20. A 3-year-old child is hospitalized because of persistent vomiting. For which condition should a nurse carefully monitor the child? a. Diarrhea b. Metabolic acidosis c. Metabolic alkalosis d. Hyperactive bowel Multiple Response Identify one or more choices that best complete the statement or answer the question.

1. A nurse is caring for multiple clients on a medical-surgical unit. Which clients should a nurse identify as being at risk for developing “third spacing?” SELECT ALL THAT APPLY. a. Client with cirrhosis b. Client with diabetes mellitus c. Client with sepsis d. Client with renal failure 2. The nurse understands that insensible fluid loss occurs through which routes? SELECT ALL THAT APPLY. a. Skin b. Lungs c. Urinary output d. Gastrointestinal tract 3. A physician orders that a client receives 0.9% sodium chloride intravenously at 150 mL/hr.

Which are characteristics of this I.V. solution? SELECT ALL THAT APPLY. a. The solution is isotonic with the plasma. b. The solution is hypotonic with the plasma. c. The solution does not affect the plasma’s osmolarity. d. The solution contains only sodium and chloride ions.

4. A client, who has been experiencing vomiting and diarrhea for several days, is admitted to a hospital with a fluid volume deficit and numerous electrolyte imbalances. Which organs are involved in the regulation of fluid and electrolyte balance in the client’s body? SELECT ALL THAT APPLY. a. Kidney b. Lung c. Pancreas d. Thyroid gland P a g e 38 | 132

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5. A nurse analyzes a client’s laboratory data and notes an increase in serum sodium, a decrease in potassium, an elevated hematocrit, and an increase in blood urea nitrogen. Based on this information, which condition should the nurse anticipate in this client? SELECT ALL THAT APPLY. a. Fluid volume excess b. Fluid volume deficit c. Decreased urinary output d. Increased urinary output 6. A client is admitted with a diagnosis of hypocalcemia. Which clinical manifestations are indicative of this diagnosis? SELECT ALL THAT APPLY. a. Tingling sensations b. Hyperactive reflexes c. Hypotonicity of the muscles d. Positive Trousseau’s sign 7. A multidisciplinary health-care team is caring for a client diagnosed with hypercalcemia.

Which treatments would be appropriate when treating this imbalance? SELECT ALL THAT APPLY. a. Calcitonin b. Inorganic phosphates c. Calcium gluconate I.V. d. Infusion of 0.45% or 0.9% sodium chloride 8. A client presents to an emergency department and is diagnosed with respiratory acidosis. A nurse caring for the client knows that respiratory acidosis may be caused by which conditions?

SELECT ALL THAT APPLY. a. Asthma b. Diabetes c. Pneumonia d. Emphysema 9. A nurse in a long-term care facility is assessing the fluid volume status of clients. Which are acceptable methods of assessing fluid volume status in an elderly adult client? SELECT ALL THAT APPLY. a. Skin turgor b. Presence of bowel sounds c. Blood pressure d. Rate and filling of veins of the hand

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Chapter 3: Fundamentals of Fluid and Electrolyte Balance Answer Section MULTIPLE CHOICE 1. ANS: C The signs and symptoms of fluid volume deficit reflect a contracted vascular compartment due to either a significant extracellular fluid (ECF) loss or an accumulation of fluid in the interstitial space. Gastrointestinal dysfunction is the most common cause of ECF deficit and the symptoms related to it, and it is most often responsible for general loss of body fluids.

PTS: 1 KEY: Cognitive Level: Analysis 2. ANS: C FVD results when water and electrolytes are lost. An increased pulse rate, decreased blood pressure, and poor skin turgor are signs of hypovolemia or FVD. PTS: 1 KEY: Cognitive Level: Application 3. ANS: B Fluid volume excess is the most accurate nursing diagnosis for this client. Extracellular fluid (ECF) volume excess causes an expansion of the ECF compartment. The primary cause of ECF excess is cardiovascular dysfunction. Clinically, ECF volume excess has distinct signs and symptoms; the most prominent are weight gain, edemas, and alterations in respiratory and cardiovascular function.

PTS: 1 KEY: Cognitive Level: Analysis 4. ANS: D A serum potassium level greater than 5.0 mEq/L is indicative of hyperkalemia. Clients who experience cellular shifting of potassium that occurs in the early stages of massive cell destruction, such as in trauma, burns, sepsis, or with metabolic or respiratory acidosis (with the exception of diabetic acidosis), are at risk for hyperkalemia. Clients with Cushing’s syndrome or colitis and the client who has been overusing laxatives are all at risk for hypokalemia.

PTS: 1 KEY: Cognitive Level: Analysis 5. ANS: D The normal serum phosphorus level is 2.5 to 4.5 mg/dL or 1.8 to 2.6 mEq/L. This client is experiencing hyperphosphatemia, and his or her phosphorus level should be lowered. Certain medications can be given to increase the fecal excretion of phosphorus by binding phosphorus to the food in the gastrointestinal tract. Aluminum hydroxide gel is one such medication. Calcium gluconate and calcium chloride are medications used in the treatment of tetany that occurs from acute hypocalcemia. Calcitonin decreases the plasma calcium level.

PTS: 1 6. ANS: B

KEY: Cognitive Level: Application

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Intestinal secretions are high in bicarbonate (HCO3) and may be lost through enteric drainage tubes, an ileostomy, or diarrhea. The decreased HCO3 level creates the base deficit of metabolic acidosis.

PTS: 1 7. ANS: C

KEY: Cognitive Level: Application

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Because this client appears to have hypokalemia, the anticipated treatment would be to replace the lost electrolyte with an infusion containing potassium chloride.

PTS: 1 KEY: Cognitive Level: Analysis 8. ANS: B There are three methods for assessment of 24-hour fluid needs for an infant. The meter square method uses a nomogram, the weight method uses the child’s weight in kilograms, and the caloric method uses guidelines on metabolic expenditure of calories.

PTS: 1 KEY: Cognitive Level: Application 9. ANS: C The guidelines for infusion of potassium are not to exceed a rate of 10 mEq/hr through peripheral veins and 10 to 20 mEq/hr through central veins. High concentrations of potassium can lead to hyperkalemia, which may affect skeletal and heart muscle, and place the client at risk for serious adverse effects, such as cardiac dysrhythmias.

Reference: Heitz, U., & Horne, M. (2005). Fluid, electrolyte and acid-base balance (5th ed.). St. Louis, MO: Elsevier/Mosby.

10.

11.

12.

13.

PTS: 1 KEY: Cognitive Level: Application ANS: B Potassium is a dynamic electrolyte. Alterations in the concentration of plasma potassium change myocardial irritability and rhythm, which could cause cardiac arrest. Reference: Phillips, L. D., & Gorski, L. (2014). Fundamentals of fluid and electrolyte balance. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application ANS: C Potassium is an intracellular electrolyte with 98% in the intracellular fluid and 2% in the extracellular fluid.

Reference: Heitz, U., & Horne, M. (2005). Fluid, electrolyte and acid-base balance (5th ed.). St. Louis, MO: Elsevier/Mosby.

PTS: 1 KEY: Cognitive Level: Application ANS: D Magnesium is an intracellular electrolyte, with approximately 35 mEq contained in the intracellular compartment and 3 mEq in the extracellular compartment. Potassium is the major intracellular cation, 98% of which is in the intracellular compartment.

Reference: Kee, J., Paulanka, B., & Polek, C. (2010). Fluids and electrolytes with clinical applications: A programmed approach (8th ed.). Clifton Park, NY: Delmar Cengage Learning.

PTS: 1 KEY: Cognitive Level: Application ANS: A Potassium, sodium, calcium, and magnesium are the positively charged electrolytes in the body fluids. Bicarbonate, phosphate, and chloride are the negatively charged electrolytes.

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Reference: Kee, J., Paulanka, B., & Polek, C. (2010). Fluids and electrolytes with clinical applications: A programmed approach (8th ed.). Clifton Park, NY: Delmar Cengage Learning.

PTS: 1

KEY: Cognitive Level: Application

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14.

15.

16.

17.

18.

19.

20.

ANS: B Alkalosis is manifested by symptoms related to decreased calcium ionization, such as tingling of fingers and toes, dizziness, and hypertonic muscles. Respirations are depressed as a compensatory action by the lungs.

Reference: Heitz, U., & Horne, M. (2005). Fluid, electrolyte and acid-base balance (5th ed.). St. Louis, MO: Elsevier/Mosby.

PTS: 1 KEY: Cognitive Level: Application ANS: B The client’s signs, symptoms, and laboratory studies indicate hypokalemia, or a decreased serum sodium level.

Reference: Heitz, U., & Horne, M. (2005). Fluid, electrolyte and acid-base balance (5th ed.). St. Louis, MO: Elsevier/Mosby.

PTS: 1 KEY: Cognitive Level: Application ANS: A Metabolic acidosis (HCO3 deficit) is a clinical disturbance characterized by a low pH and low plasma HCO3 level. This condition can occur by a gain of hydrogen ion or a loss of HCO3.

Reference: Heitz, U., & Horne, M. (2005). Fluid, electrolyte and acid-base balance (5th ed.). St. Louis, MO: Elsevier/Mosby.

PTS: 1 KEY: Cognitive Level: Application ANS: A Renal failure and inadequate excretion of magnesium by the kidneys is the most common cause of hypermagnesemia.

Reference: Heitz, U., & Horne, M. (2005). Fluid, electrolyte and acid-base balance (5th ed.). St. Louis, MO: Elsevier/Mosby.

PTS: 1 KEY: Cognitive Level: Application ANS: C The normal range for arterial blood is 7.35 to 7.45. This reflects the blood’s hydrogen ion concentration.

Reference: Heitz, U., & Horne, M. (2005). Fluid, electrolyte and acid-base balance (5th ed.). St. Louis, MO: Elsevier/Mosby.

PTS: 1 KEY: Cognitive Level: Application ANS: A After adding medication to a bag of I.V. solution, the nurse should gently agitate or rotate the bag to evenly mix the medication in the solution. The nurse should then attach the label stating the name and amount of the medication added.

Reference: Phillips, L. D., & Gorski, L. (2014). Fundamentals of fluid and electrolyte balance. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 ANS: C

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Reference: Phillips, L. D., & Gorski, L. (2014). Fundamentals of fluid and electrolyte balance. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.).

Philadelphia, PA: F.A. Davis.

PTS: 1

KEY: Cognitive Level: Application

MULTIPLE RESPONSE 1. ANS: A, C, D The nurse should identify the clients diagnosed with cirrhosis, sepsis, and renal failure as being at risk for developing third spacing. Risk factors include liver or kidney disease, major trauma, burns, sepsis, wound healing or major surgery, malignancies, gastrointestinal malabsorption, and malnutrition. Alcoholic or older adult clients are also at risk. Third-space fluid (“third spacing”) is physiologically useless because it does not circulate to provide nutrients for the cells.

Reference: Heitz, U., & Horne, M. (2005). Fluid, electrolyte, and acid-base balance. St. Louis, MO: Elsevier/Mosby.

PTS: 1 KEY: Cognitive Level: Analysis 2. ANS: A, B Insensible losses occur through the skin and the lungs. Sensible losses are those of which a person is aware, such as losses through wound drainage, the gastrointestinal tract, and urination.

Reference: Phillips, L. D., & Gorski, L. (2014). Fundamentals of fluid and electrolyte balance. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Knowledge 3. ANS: A, C, D A solution of 0.9% sodium chloride has only 154 mEq sodium and 154 mEq chloride. This solution is isotonic and is frequently used for I.V. infusion because it does not affect the plasma’s osmolarity. A fluid into which cells can be placed without affecting the cell size is described as being isotonic with the cells. A hypotonic solution would draw fluid into the cells and would expand the intracellular compartment.

Reference: Phillips, L. D., & Gorski, L. (2014). Fundamentals of fluid and electrolyte balance. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 4. ANS: A, B, D The kidney, lung, and thyroid gland are organs that are responsible for both fluid and electrolyte balance (homeostasis) in the body. The pancreas is not an organ that directly regulates fluid and electrolytes.

Reference: Kee, J., Paulanka, B., & Polek, C. (2010). Fluids and electrolytes with clinical applications: A programmed approach (8th ed.). Clifton Park, NY: Delmar Cengage Learning.

PTS: 1 5. ANS: B, C

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Fluid volume deficit that is attributable to dehydration causes altered serum blood levels, with an increase in hematocrit levels, blood urea nitrogen, and serum osmolarity. Urine output would be decreased as the body attempts to conserve water, and urine specific gravity would likely be elevated.

Reference: Kee, J., Paulanka, B., & Polek, C. (2010). Fluids and electrolytes with clinical applications: A programmed approach (8th ed.). Clifton Park, NY: Delmar Cengage Learning.

PTS: 1 KEY: Cognitive Level: Application 6. ANS: A, B, D Clinical manifestations of hypocalcemia include tingling sensations, hyperactive reflexes, and a positive Trousseau’s sign. Neurological and cardiac abnormalities are common. Tetanus is the most characteristic manifestation; the entire symptom complex is induced by increased neural excitability. Hypotonicity of the muscles is a symptom of hypercalcemia.

Reference: Kee, J., Paulanka, B., & Polek, C. (2010). Fluids and electrolytes with clinical applications: A programmed approach (8th ed.). Clifton Park, NY: Delmar Cengage Learning.

PTS: 1 KEY: Cognitive Level: Application 7. ANS: A, B, D Calcitonin decreases the serum calcium level by 1 to 3 mg/100 mL. Infusion of 0.45% or 0.9% sodium chloride causes a saline diuresis, reducing the serum calcium. Inorganic phosphates bind the calcium. Calcium gluconate is used for treatment of hypocalcemia.

Reference: Heitz, U., & Horne, M. (2005). Fluid, electrolyte and acid-base balance (5th ed.). St. Louis, MO: Elsevier/Mosby.

PTS: 1 KEY: Cognitive Level: Application 8. ANS: A, C, D Respiratory acidosis is caused by inadequate excretion of carbon dioxide and inadequate ventilation. Acute respiratory acidosis is usually associated with pulmonary, neurologic, and cardiac causes, not with endocrine conditions.

Reference: Kee, J., Paulanka, B., & Polek, C. (2010). Fluids and electrolytes with clinical applications: A programmed approach (8th ed.). Clifton Park, NY: Delmar Cengage Learning.

PTS: 1 KEY: Cognitive Level: Application 9. ANS: A, D Fluid balance in elderly people is affected by the physiological changes associated with aging.

Total body water is reduced by 6%, causing decreased skin turgor and decreased filling of peripheral veins. The client should be assessed for his or her ability to obtain fluids because as aging progresses, the thirst mechanism decreases.

Reference: Phillips, L. D., & Gorski, L. (2014). Fundamentals of fluid and electrolyte balance. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.).

Philadelphia, PA: F.A. Davis.

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Chapter 4: Parenteral Solutions Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A nurse administers a parenteral solution to a client that contains portions of electrolytes, similar to plasma, as well as bicarbonate. The nurse is administering a(n): a. hypotonic solution. b. isotonic solution. c. balanced solution. d. hypertonic solution.

2. A client presents in an emergency department and is diagnosed with fluid volume deficit. A nurse begins I.V. therapy per a physician’s order to replace the client’s lost fluids. Which hypotonic I.V. solution should the nurse anticipate being ordered for this client? a. 0.45% sodium chloride b. 5% dextrose in water c. 10% dextrose in water d. 5% dextrose in 0.9% sodium chloride 3. An emergency department nurse is administering a colloidal I.V. solution to a client diagnosed with hypovolemia. Which solution, administered by the nurse, is considered a colloid solution? a. Lactated Ringer’s b. Albumin c. 5% dextrose in water d. 5% dextrose in 0.45% sodium chloride 4. A nurse is preparing to begin fluid replacement therapy on an older adult, dehydrated client.

Before a client is started on replacement therapy, which physiological function should be assessed? a. Respiratory function b. Renal function c. Endocrine function d. Adrenal function 5. A nurse prepares to administer a blood transfusion to a client. Which I.V. solution is the only acceptable solution for the nurse to use to prime the administration set before administering blood? a. Lactated Ringer’s solution b. 5% dextrose in water c. 0.9% sodium chloride d. 5% dextrose and 0.45% sodium chloride 6. A pediatric nurse is preparing to administer a hypotonic I.V. solution to a child experiencing profound dehydration. Which solution would be considered a hydrating solution? a. 5% dextrose in water b. Lactated Ringer’s solution P a g e 48 | 132

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Chapter 4: Parenteral Solutions Answer Section MULTIPLE CHOICE 1. ANS: C The nurse is administering a balanced solution. Hypotonic, isotonic, and hypertonic solutions refer only to those solutions whose osmolarity is, respectively, less than, equal to, or greater than that of plasma—not to their electrolyte or ionic contents.

PTS: 1 KEY: Cognitive Level: Analysis 2. ANS: A The solution of 0.45% sodium chloride is hypotonic and has an osmolarity of 155. It is one of the only hypotonic solutions used in clinical practice. The range for hypotonic solutions is below 250 mOsm. Five percent dextrose in water has an osmolarity of 252 mOsm and is isotonic; 10% dextrose in water has an osmolarity of 505 mOsm and is hypertonic; 5% dextrose and 0.9% sodium chloride combined has an osmolarity of 560 mOsm and is hypertonic.

PTS: 1 KEY: Cognitive Level: Application 3. ANS: B Albumin is a natural plasma protein prepared from donor plasma. Colloid solutions contain protein or starch molecules that remain distributed in the extracellular space and do not form a “true” solution.

PTS: 1 KEY: Cognitive Level: Application 4. ANS: B The first concern for a client requiring replacement is whether the kidneys are functioning well enough to permit the therapy.

PTS: 1 KEY: Cognitive Level: Application 5. ANS: C Saline solutions are the only solution to be used with any blood product. Dextrose solutions cause hemolysis of cells. Lactated Ringer’s solutions contain calcium ions that can also hemolyze the blood cells.

Reference: Roback, J. D., Combs, M. R., & Grossman, B. et al. (2008). Technical manual (16th ed.).

MD: American Association of Blood Banks.

PTS: 1 KEY: Cognitive Level: Application 6. ANS: D Solutions that contain dextrose and hypotonic saline provide more water than is required for excretion of salt and are also useful as hydrating fluids.

Reference: Phillips, L. D., & Gorski, L. (2014). Parenteral solutions. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

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Chapter 5: Infusion Equipment Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A nurse is preparing to administer a preoperative antibiotic I.V. piggyback. Which connection should be used to secure a piggyback administration set to the primary administration set? a. Slide clamp b. Luer lock c. Slip lock d. Taping with paper tape 2. The product evaluation committee at a local hospital has decided to purchase a needleless I.V. system to be used throughout the organization. For which reason did the team most likely make this decision? a. To protect the I.V. line’s integrity b. To decrease tubing changes c. To enable quicker blood draws d. To decrease the risk for needlestick injuries 3. A nurse is inspecting a container of infusate before client administration. To ensure integrity of a flexible plastic infusate solution container, the nurse should check for: a. solution clarity, expiration date, and air vents. b. solution clarity, expiration date, and punctures. c. punctures, cracks, presence of ports, and clarity. d. punctures, expiration date, and presence of ports.

4. The nurse wants to maintain the integrity of a peripheral venous catheter. According to Infusion Nurses Society Standards of Practice (2011), peripheral intermittent locking devices must be kept patent following each catheter use with: a. heparin. b. medication. c. 0.9% bacteriostatic sodium chloride. d. combination of sodium chloride followed by heparin flush.

5. A nurse is preparing an I.V. infusion using a Y-type infusate administration set. The nurse is most likely using this administration set to administer: a. total parenteral nutrition. b. fat emulsion. c. primary I.V. solution. d. packed red cells.

6. A nurse is preparing to administer I.V. cyclosporine. To prevent leaching of diethylhexyl phthalate (DEHP) by this medication, the nurse should ensure that: a. the pharmacy provides the cyclosporine in a polyvinyl chloride (PVC) bag. b. cyclosporine is compatible with the client’s other medications. c. the cyclosporine is administered through non-PVC I.V. tubing. d. cyclosporine is administered by a physician.

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Multiple Response Identify one or more choices that best complete the statement or answer the question.

1. A critical-care nurse is using a 0.22-mm filter for the delivery of infusion therapy. According to the Infusion Nurses Society Standards of Practice (2011), for nonlipid-containing solutions that require filtration, a 0.2-mm filter should be a. air eliminating. b. particulate retentive. c. fat emboli reducing. d. bacterial retentive.

2. A client with osteomyelitis is admitted to the acute-care hospital to begin infusion therapy. The client needs infusion therapy for 3 weeks and has poor venous access. The I.V. team registered nurses are competent to insert peripherally inserted central catheters, as well as midline catheters. Which should be taken into consideration when selecting the most appropriate venous access device? SELECT ALL THAT APPLY. a. The pH and osmolarity of prescribed therapy b. The interventional radiology support c. The time it takes to insert the venous access device d. The patient’s understanding and caregiver support for managing catheter upon discharge

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Chapter 5: Infusion Equipment Answer Section MULTIPLE CHOICE 1. ANS: B The male Luer lock has threads that secure and lock the connectors. Taping connectors is not acceptable practice. The slide clamp does not secure connectors but regulates the rate. A slip lock is a type of male adapter that slips into the female end of the equipment; however, there is no mechanism to secure the two pieces of equipment.

PTS: 1 KEY: Cognitive Level: Application 2. ANS: D It is now required that needleless systems be used whenever the risk for needlestick injury can occur from I.V. piggyback, push, or withdrawal of medication from a vial.

PTS: 1 KEY: Cognitive Level: Application 3. ANS: B .

Plastic infusion containers need to be checked for punctures to the plastic material, expiration date of the infusate, and integrity of the solution.

Reference: Phillips, L. D., & Gorski, L. (2014). Parenteral solutions. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 4. ANS: C Short peripheral catheters should be locked with preservative-free 0.9% sodium chloride (USP) following each catheter use in adults and children.

Reference: Infusion Nurses Society. (2011). Infusion Nursing Standards of Practice. Journal of Infusion Nursing, 34(1S), S60.

PTS: 1 KEY: Cognitive Level: Application 5. ANS: D Y infusate sets are used for administration of blood to facilitate the priming infusate (0.9% sodium chloride) and the blood bag.

Reference: Phillips, L. D., & Gorski, L. (2014). Parenteral solutions. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 6. ANS: C To prevent leaching, the nurse should ensure that the cyclosporine is provided in a non-PVC bag and administered through non-PVC tubing. DEHP is a plasticizer that is used to add softness and pliability to PVC material. Some drug formulations that contains surfactants, such as P a g e 53 | 132

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cyclosporine, leach this plasticizer out of the plastic matrix and into the solution. This can cause DEHP-induced toxicity.

Reference: Phillips, L. D., & Gorski, L. (2014). Parenteral solutions. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

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PTS: 1

KEY: Cognitive Level: Application

MULTIPLE RESPONSE 1. ANS: A, B, D A 0.2-mm filter is considered a bacterial/particulate retentive air-eliminating filter and is recommended. Lipid filters are 1.2 mm.

Reference: Infusion Nurses Society. (2011). Infusion Nursing Standards of Practice. Journal of Infusion Nursing, 34(1S), S33.

PTS: 1 KEY: Cognitive Level: Application 2. ANS: A, B, D If the pH of the solutions is above 9 or below 5, or if the osmolarity is above 600 mOsm, then a PICC is needed to deliver the infusion to larger veins of the superior vena cava. The PICC must be read and verified by x-ray before use. The client will be discharged before 3 weeks; therefore, discharge planning must begin upon admission with choice of venous access device.

Reference: Phillips, L. D., & Gorski, L. (2014). Parenteral solutions. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1

KEY: Cognitive Level: Application

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Chapter 6: Peripheral I.V. Catheters: Initiation and Maintenance of Peripheral Infusion Therapy Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A client is being discharged to home with continuous I.V. infusion therapy. Which assessment made by the nurse before proceeding with the discharge plan is most important? a. If the client lives alone b. If the client is medically stable c. If the client has a working telephone d. If the client has a working refrigerator 2. A nurse is time-taping an I.V. bag of 1,000 mL that is to infuse over 8 hours. The nurse places the 1100 hour marking at the 500-mL level. At which level should the nurse place the mark for 1200 hours? a. 350 mL b. 375 mL c. 400 mL d. 425 mL 3. A nurse is inspecting a container of infusate prior to client administration. Prior to use, the infusate solution container should be inspected for: a. clarity, the expiration date, and air vents. b. clarity, the expiration date, and punctures or cracks. c. clarity, punctures or cracks, and the number of access ports. d. the number of access ports, the expiration date, and floating particles.

4. A nurse is initiating infusion therapy for a client using a Teflon over-the-needle catheter (ONC).

The major hazard associated with the use of Teflon ONCs for peripheral infusion is: a. risk for phlebitis. b. risk for infiltration. c. that they can be used for only 24 hours. d. that they can remain in place for only 48 hours.

5. A medical-surgical nurse is caring for multiple clients who have peripheral I.V. access devices.

According to the Centers for Disease Control and Prevention (CDC), how often should the nurse change the clients’ I.V. catheters? a. As needed (PRN) b. At 24- to 48-hour intervals c. At 48- to 72-hour intervals d. At 72- to 96-hour intervals 6. A nurse is calculating the drip rate before initiating an I.V. infusion. Upon which factor(s) should the calculation of the drip rate depend? a. Drop factor of tubing b. Tubing length and filter size c. Drop factor of the tubing and physician order of mL/hr d. Filter size and number of injection ports on administration set P a g e 56 | 132

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7. A nurse is preparing to initiate an I.V. infusion on a 3-year-old child. Which action should be taken by the nurse initially? a. Explain the procedure completely. b. Explain the procedure in simple terms. c. Restrain the child to perform the venipuncture. d. Provide reading materials before performing venipuncture.

8. A nurse is attempting to obtain venous access on a 2-month-old infant. Which cannula size should the nurse select for use with this client? a. 16-gauge scalp vein (metal) needle b. 18-gauge over-the-needle catheter (ONC) c. 22- to 24-gauge ONC d. 23- to 25-gauge scalp vein (metal) needle 9. A nurse is preparing to initiate an I.V. infusion on a toddler. To prevent fluid overload, the nurse understands that the toddler’s I.V. container should contain no more than: a. 500 mL of fluid. b. 1,000 mL of fluid. c. 24-hour volume requirements of fluid. d. hourly volume requirements of fluid.

10. A nurse is preparing to administer an I.V. potassium infusion I.V. piggyback to an older adult client diagnosed with hypokalemia. Which age-related body change may cause increased cardiac sensitivity to potassium infusion? a. Decreased muscle strength and a loss of bone density b. Decreased cough efficiency and decreased vital capacity c. Decreased salivation and decreased gastrointestinal motility d. Decreased lean body mass and decreased glomerular filtration rate 11. A physician orders an I.V. infusion for a dehydrated older adult client diagnosed with congestive heart failure. A nurse prepares to implement the physician’s order. Which would be an appropriate choice of infusion equipment for the older adult client with cardiovascular compromise? a. Inline filter b. T adapter c. Three-way stopcock d. Microdrop administration set 12. A prudent medical-surgical nurse frequently monitors the I.V. sites of his older adult clients because: a. older adult clients always pull at their I.V. lines. b. the veins of older adults always rupture, causing infiltration. c. older adult clients need to be mobile, therefore placing I.V. patency at risk. d. age-related neurologic changes can reduce tactile sensation, allowing infiltration or phlebitis to become severe before the client notices any discomfort.

13. A nurse is applying a transparent, semipermeable membrane dressing to an I.V. site. The nurse should take care to place the dressing so that it: P a g e 57 | 132

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a. b.

covers only the area surrounding the I.V. entry site. can be removed for observation of the site every 4 hours.

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c. d.

covers the area surrounding the I.V. entry site up to the top margin of the cannula hub to help stabilize the cannula. covers the I.V. entry site, the catheter hub, and the connection between the I.V. device and the administration set tubing.

14. A client is scheduled for surgical insertion of a midline catheter. A nurse explains to the client that a midline catheter is any peripheral catheter that is placed: a. with the tip in any location between the antecubital fossa and the subclavian vein. b. between the antecubital fossa and 3 to 5 cm distal to the axillary vein. c. between the antecubital fossa and 6 to 8 cm proximal to one of the innominate veins. d. between the antecubital fossa and the head of the clavicle, with optimal tip location level with the axilla.

15. According to Infusion Nurses Society Standards of Practice (2011), which of the following should be used to secure the infusion device after insertion? a. Paper tape b. Stabilization device c. Sutures d. Combination of transparent, semipermeable membrane dressing and tape Multiple Response Identify one or more choices that best complete the statement or answer the question.

1. A nurse is selecting a peripheral vein for I.V. access. Which factors should affect the nurse’s choice of an I.V. site? SELECT ALL THAT APPLY. a. Type of solution b. Condition of vein c. Whether client is right or left handed d. Presence of disease, shunts, or grafts in the extremity 2. A critical care nurse is using a 0.22-mm filter for the delivery of infusion therapy. According to the Infusion Nurses Society’s Standards of Practice (2011), for nonlipid-containing solutions that require filtration, a 0.2-mm filter should be: a. air eliminating. b. particulate retentive. c. fat emboli reducing. d. bacterial retentive.

3. Documentation of initiation of a short-peripheral infusion (PIV) device should include which of the following? a. Device type, length, and gauge b. Manufacturer and lot number c. Date and time of insertion d. Number and location of attempts 4. A nurse is preparing to start a 30-year-old adult, normotensive client’s I.V. line. Which techniques best assist the nurse in distension of veins before cannulation? SELECT ALL THAT APPLY. P a g e 59 | 132

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a. b. c. d.

Application of a blood pressure cuff with setting of 30 mm Hg Placing a cool compress over the site for 10 minutes Placing a warm compress over the site for 10 minutes Use of multiple tourniquet techniques

5. A pediatric intensive care unit nurse is preparing to obtain an I.V. access using an infant’s scalp vein. The nurse is thinking critically about which type of catheter to use. What are the advantages of over- the-needle catheter (ONCs) needles over metal scalp vein needles? SELECT ALL THAT APPLY. a. ONCs are radiopaque. b. ONCs are patent longer than scalp vein needles. c. ONCs have decreased infiltration risks. d. ONCs have a low incidence of mechanical phlebitis.

6. A nurse is selecting a peripheral vein for venipuncture. Which factors should affect the nurse’s choice of an I.V. site? SELECT ALL THAT APPLY. a. Condition of the vein b. Client’s preference c. Duration of therapy d. Type of solution to be administered e. Presence of disease, shunts, or grafts in the extremity 7. A nurse has finished placing a 20-gauge over-the-needle catheter in a client’s forearm for a continuous infusion of 1000 mL of 5% dextrose and 0.45% sodium chloride. After the infusion has been initiated, which items should be labeled? SELECT ALL THAT APPLY. a. Tubing b. Catheter site c. Solution container d. Client’s armband 8. A nurse is initiating I.V. therapy on a client who is receiving anticoagulant therapy.

Which techniques should the nurse use when starting an I.V. line on this client? a. Avoid use of a tourniquet if possible or apply loosely. b. Avoid excess pressure when cleansing the skin. c. Use alcohol to loosen dressing. d. Use multiple tourniquet technique to dilate vein.

Completion Complete each statement.

1. A physician orders 1,000 mL of 5% dextrose and lactated Ringer’s solution infused intravenously at 80 mL/hr. The nurse time-tapes the bag with a start time of 0700 hours. Based on this information, the infusion should be complete at hours. Fill in the blank.

2. A physician orders 1,000 mL of 5% dextrose in water at 50 mL/hr. A nurse uses tubing with a drop factor of 15. The nurse calculates that the I.V. solution should be infused at drops per minute (gtt/min). Fill in the blank.

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3. A physician orders 1,000 mL of 5% dextrose and 0.45% sodium chloride to be infused intravenously at 125 mL/hr. A nurse uses tubing with a drop factor of 20. The nurse calculates that the I.V. solution should be infused at drops per minute (gtt/min). Fill in the blank.

4. A child who weighs 10 kg sustains an estimated total body surface area (TBSA) burn of 50% from a house fire. The Parkland formula of fluid resuscitation is used to determine the amount of fluid that this child requires. According to this formula, a nurse should intravenously administer mL of fluid to the child in the first 8 hours from the time of the injury. Fill in the blank.

5. A physician orders 0.45% sodium chloride to be infused intravenously at 45 mL/hr for an 8month- old infant. A nurse calculates that, using a microdrip controller, the solution should infuse at a rate of drops per minute (gtt/min). Fill in the blank.

Short Answer 1. A nurse has just successfully inserted an I.V. cannula into a client’s vein. Which action should be taken by the nurse next? Place each nursing action in the order of priority. a.

Adjust the flow rate. b.

Attach the primed I.V. tubing. c.

Observe for signs of infiltration. d.

Begin the flow of I.V. fluid.

2. A nurse is preparing to flush a client’s I.V. catheter before injecting medication. Which steps should be taken by the nurse when flushing the client’s intermittent locking device? Prioritize the nurse’s actions by placing each step in the correct order. a.

Flush with sodium chloride using push-pause method. b.

Check for patency of the catheter. c.

Administer the medication. d.

Flush with sodium chloride applying positive pressure.

3. A nurse is preparing to flush a client’s I.V. catheter before injecting medication. Which steps should be taken by the nurse when flushing the client’s intermittent locking device? Prioritize the nurse’s actions by placing each step in the correct order. a.

Flush with sodium chloride using push-pause method. b.

Check for patency of the catheter. c.

Administer the medication.

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d.

Flush with sodium chloride applying positive pressure.

Chapter 6: Techniques for Initiation and Maintenance of Peripheral Infusion Therapy Answer Section MULTIPLE CHOICE 1. ANS: A One common criterion for continuous I.V. infusion therapy in the home setting is having a parttime or full-time caregiver to assist the client with the therapy. Therefore, the nurse should determine whether the client lives alone. The client should also be medically stable, have a refrigerator (for storage of infusion supplies), and have access to a telephone.

PTS: 1 KEY: Cognitive Level: Analysis 2. ANS: B If the I.V. is scheduled to run over 8 hours, then the hourly rate would be 125 mL/hr. Using 500 mL as the reference point, the next hourly marking should be at 375 mL, which is 125 mL less than 500 mL. PTS: 1 KEY: Cognitive Level: Analysis 3. ANS: B To ensure the integrity of solutions that are administered to clients, the nurse must check the solution’s clarity and expiration date before connection to the administration set. To check a glass system for damage, hold the glass bottle up to the light and check for flashes of light and floating particles or discoloration. The glass system should be crystal clear. Squeeze plastic containers to check for pinholes or punctures to the system.

PTS: 1 KEY: Cognitive Level: Application 4. ANS: A Teflon ONCs tend to increase the risk for infusion-related phlebitis with small peripheral catheters. Reference: Maki, D.G., & Mermel, L. A. (2008). Infections due to infusion therapy. In W. R. Javis (Ed.), Bennett & Brachman’s hospital infections (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

PTS: 1 KEY: Cognitive Level: Application 5. ANS: D The CDC (2009) recommends changing a client’s I.V. catheter no more frequently than 72 to 96 hours as long as the hospital phlebitis rate is less than 5%.

Reference: O’Grady, N., & Alexander, M. (2011). Guidelines for prevention of intravascular catheter-related infections. Atlanta, GA: Centers for Disease Control and Prevention.

PTS: 1 KEY: Cognitive Level: Application 6. ANS: C To accurately calculate drops per minute, the nurse should know the manufacturer’s drop factor of tubing and the amount to be infused over a given hour.

PTS: 1

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The stage of development for a 3-year-old child, according to Erikson, is initiative versus guilt— the major stressor of which is loss of control. There is a fear at this age of bodily injury, intrusive procedures, and mutilation. Explanations should be simple and direct. Allow the child to express protest but provide play and diversional activity.

PTS: 1 KEY: Cognitive Level: Analysis 8. ANS: C The choice of needle depends on the site selected for insertion; however, a 22- to 24-gauge ONC is most commonly used with infants because of their small vessel size.

PTS: 1 KEY: Cognitive Level: Analysis 9. ANS: C The nurse should consider use of small-volume containers in infants and toddlers because of complications of fluid volume overload. The volume of the solution container should be based on the age, height, and weight or body surface area of the toddler and should contain no more than the 24- hour volume requirement.

10.

11.

12.

13.

14.

PTS: 1 KEY: Cognitive Level: Application ANS: D Frail, older adults are at risk for developing increased cardiac sensitivity to potassium infusion because of decreased lean body mass and decreased glomerular filtration rate associated with age. Serum potassium must be closely monitored. The kidneys excrete potassium.

PTS: 1 KEY: Cognitive Level: Application ANS: D To prevent fluid overload, a microdrop administration set should be used when appropriate.

Inline filters, three-way stopcocks, and T adapters do not regulate infusions and have no effect on the client’s cardiovascular status.

PTS: 1 KEY: Cognitive Level: Analysis ANS: D The physiological changes that occur in aging produce changes that affect a client’s ability to feel for changes in I.V. catheter integrity.

PTS: 1 KEY: Cognitive Level: Analysis ANS: C This technique is used to allow the hub to be accessed for changes in administration set or adding a locking device and allows for stabilization of the catheter.

Reference: Phillips, L. D., & Gorski, L. (2014). Techniques for initiation and maintenance of peripheral infusion therapy. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 ANS: D

KEY: Cognitive Level: Application

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A midline catheter, usually 6 inches in length, is placed percutaneously between the antecubital fossa and the head of the clavicle. The catheter is then advanced into larger vessels below the axilla, where there is good hemodilution. The midline catheter is intended for intermediate-term therapy of 1 to 4 weeks.

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Reference: Phillips, L. D., & Gorski, L. (2014). Techniques for initiation and maintenance of peripheral infusion therapy. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

15.

PTS: 1 KEY: Cognitive Level: Application ANS: B Use of a catheter stabilization device is preferred to tape or sutures when feasible. Several studies have demonstrated a reduction in overall complications and improved dwell time with PIV catheters. Also has been demonstrated is reduced risk of infections with peripherally inserted central lines.

Reference: Infusion Nurses Society. (2011). Infusion Nursing Standards of Practice. Journal of Infusion Nursing, 34(1S), S46.

PTS: 1

KEY: Cognitive Level: Application

MULTIPLE RESPONSE 1. ANS: A, B, D The type of solution, the condition of the vein, and the presence of disease, shunts, or grafts in the extremity are factors that affect the nurse’s choice of I.V. sites. With the over-the-needle catheter flexibility, the client can use either hand with catheter placement and secure taping and dressing.

PTS: 1 KEY: Cognitive Level: Application 2. ANS: A, B, D A 0.2-mm filter is considered a bacterial/particulate retentive air-eliminating filter and is recommended. Lipid filters are 1.2 mm.

Reference: Infusion Nurses Society. (2011). Infusion Nursing Standards of Practice. Journal of Infusion Nursing, 34(1S), S33.

PTS: 1 KEY: Cognitive Level: Application 3. ANS: A, C, D Information about the catheter, date and time and number of attempts are required for documentation when inserting a PIV. Manufacturer and lot number are additional requirements with central vascular access devices.

Reference: Infusion Nurses Society. (2011). Infusion Nursing Standards of Practice. Journal of Infusion Nursing, 34(1S), S20.

PTS: 1 KEY: Cognitive Level: Application 4. ANS: A, C Warmth vasodilates the veins, making them distend for visualization. Use of a blood pressure cuff can distend the veins for appropriate I.V. access. Cold causes vasoconstriction. Multiple tourniquet technique is reserved for difficult I.V. access when visualization of veins is difficult due to extra adipose tissue.

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Reference: Phillips, L. D., & Gorski, L. (2014). Techniques for initiation and maintenance of peripheral infusion therapy. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1

KEY: Cognitive Level: Application

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5. ANS: A, B, C ONCs remain in the vein longer than metal scalp vein needles, are radiopaque for visualization on radiography, and infiltrate less frequently than the metal scalp vein needles. ONCs carry a higher risk for phlebitis than metal needles.

Reference: Phillips, L. D., & Gorski, L. (2014). Techniques for initiation and maintenance of peripheral infusion therapy. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 6. ANS: A, C, D, E Several factors should be considered before a venipuncture is attempted to help the nurse make a competent choice of location for the infusion. Those factors include condition of the vein, duration of therapy, type of solution, presence of a shunt or graft in the extremity, cannula size, client age and activity, and presence of disease or prior surgery. Client preference is a consideration only when all other factors have been evaluated.

Reference: Phillips, L. D., & Gorski, L. (2014). Techniques for initiation and maintenance of peripheral infusion therapy. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 7. ANS: A, B, C With a continuous infusion, the bag should be time stripped, the administration set should be flagged with a label for when it is to be changed, and the site should be labeled with the date, time, size, and length of the catheter and the initials of the nurse.

Reference: Phillips, L. D., & Gorski, L. (2014). Techniques for initiation and maintenance of peripheral infusion therapy. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 8. ANS: A, B, C Clients receiving anticoagulant therapy have a propensity to bleed. Local hematoma can be avoided if the nurse avoids the use of a tourniquet, avoids excessive pressure when cleansing the skin, and uses alcohol or adhesive remover when removing an adhesive dressing.

Reference: Phillips, L. D., & Gorski, L. (2014). Techniques for initiation and maintenance of peripheral infusion therapy. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1

KEY: Cognitive Level: Application

COMPLETION 1. ANS: 1930 At a rate of 80 mL/hr, an infusion of 1,000 mL will be finished in 12.5 hours. Using military time, the completion time will be 19:30.

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2. ANS: 13 mL/hr × drop factor = drops/min min/hr 50 × 15 = 12.499 = 13 gtt/min 60 PTS: 1 KEY: Cognitive Level: Analysis 3. ANS: 42 mL/hr × drop factor = drops/min min/hr 125 × 20 = 41.66 = 42 gtt/min 60 PTS: 1 KEY: Cognitive Level: Analysis 4. ANS: 1,000 The Parkland formula is: 4 mL of lactate solution × kg of body weight × % of TBSA burned 4 mL × 10 kg × 50% = 2,000 mL This formula also states that half of the amount is given over the first 8 hours, one fourth is administered in the second 8 hours, and one fourth of the total in the third 8 hours after being burnt. Reference: Heitz, U., & Horne, M. (2005). Fluid, electrolyte, and acid-base balance. St. Louis, MO: Elsevier/Mosby.

PTS: 1 KEY: Cognitive Level: Analysis 5. ANS: 45 mL/hr × drop factor = drops/min min/hr 45 × 60 = 45 gtt/min 60 Microdrip sets are 60 gtt. If infusing over 1 hour, 60 and 60 cancel each other. When using microdrip sets, the gtt/min is the same as the mL/hr.

Reference: Phillips, L. D., & Gorksi, L. (2014). Phlebotomy techniques. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1

KEY: Cognitive Level: Analysis

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b, d, a, c After cannulating the vein and removing the stylet, the nurse should attach the primed administration set to the catheter hub. The nurse should then release the tourniquet, start the flow of I.V. solution, and adjust the flow rate. Finally, the nurse should observe the site for signs of infiltration.

PTS: 1 KEY: Cognitive Level: Analysis 2. ANS: b, a, c, d The catheter patency in the lumen of the vein must be established before injecting substances into the vascular system. The next steps are to flush with sodium chloride, administer the medication, and flush with sodium chloride again to remove residual medication from the lock, using positive pressure to fill the lock.

Reference: Phillips, L. D., & Gorski, L. (2014). Techniques for initiation and maintenance of peripheral infusion therapy. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 3. ANS: b, a, c, d The catheter patency in the lumen of the vein must be established before injecting substances into the vascular system. The next steps are to flush with sodium chloride, administer the medication, and flush with sodium chloride again to remove residual medication from the lock, using positive pressure to fill the lock.

Reference: Phillips, L. D., & Gorski, L. (2014). Techniques for initiation and maintenance of peripheral infusion therapy. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1

KEY: Cognitive Level: Application

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Chapter 7: Phlebotomy Techniques Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A nurse is preparing to draw blood from an older adult client using a butterfly safety needle. Which is the best angle for needle insertion during venipuncture?

A. 25 degrees B. 35 degrees C. 45 degrees D. 90 degrees Ans: A 2. A physician orders multiple blood tests for a client. A nurse preparing to collect blood samples knows that most diagnostic blood tests require: A. anticoagulants.

B. shaking.

C. lancets.

D. syringes.

Ans: A 3. A quality-control nurse reviews procedures to decrease the incidence of errors in a hospital laboratory.

Which type of test requisition has been shown to decrease laboratory errors?

A. Bar coded B. Computer C. Manual triplicate forms D. Verbal requests Ans: A 4. The nurse has an order test blood on a 93-year old client diagnosed with diabetes. Which method of blood collection is the best for this client?

A. Evacuated tube system B. Syringe method C. Capillary puncture D. VAD withdrawal Ans: A 5. How does the nurse’s facility help minimize laboratory personnel’s risk of exposure to blood during blood collection?

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D. Use of the capillary puncture Ans: A 6. Anticoagulants are used as an additive in blood collection tubes to prevent blood clotting.

Which anticoagulant additive prevents clotting by inactivating clotting chemicals in thrombin and thromboplastin?

A. Oxalate B. Citrate C. EDTA D. Hepari n Ans: D 7. The nurse performs a venipuncture on a newly admitted client who has a diagnosis of dehydration.

What is the most common complication that the nurse has seen from performing a venipuncture?

A. Hematoma formation B. Iatrogenic anemia C. Infection D. Nerve injury Ans: A 8. The nurse is attempting to place an IV in a client’s arm at a site from a previous hospitalization. Why would the nurse need to further assess this attempt?

A. Numerous venipunctures can cause a buildup of scar tissue.

B. Use of this site may cause a hematoma to form.

C. Venipuncture of this site may cause an extravasation.

D. The client may require a PICC line due to peripheral IV overuse. Ans: A 9. The nurse is preparing to place an IV in the forearm of a five-year old child. What is the nurse’s most therapeutic comment?

A. “This may pinch a bit, but it will be over quickly.”

B. “This will not hurt a bit, and it will be over quickly.”

C. “When this is over you can have a piece of candy.”

D. “This won't hurt, and you can have a piece of candy.” Ans: A 10. The nurse is preparing to place an IV in the forearm of an elderly client. Which age-related change may require the expert skills from a phlebotomist?

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D. Iatrogenic anemia Ans: A

11. The nurse has an order to draw labs on a client diagnosed with possible sepsis. What is the correct order of blood collection draw to prevent contamination? SELECT ALL THAT APPLY. A. Blood culture vials, gold top, gray top B. Blood culture tubes, light blue top, red top C. Blood culture tubes, green top, gray top D. Gray top, pink top, green top Ans: BC 1. A clinic nurse is performing venipuncture on multiple clients. Which complications of venipuncture is the client at risk for that the nurse should anticipate when performing a venipuncture on a new client? (Select all that apply.)

A. Hematoma B. Continued bleeding C. Nerve injury D. Traumatic neuroma E. Vein damage Ans: ABC

12. A nurse is preparing to obtain a blood sample from an infant. Which precautions should the nurse take when obtaining blood from a capillary puncture in an infant? (Select all that apply.)

A. Do not puncture deeper than 2.0 mm.

B. Do not puncture over bruised areas.

C. Obtain puncture over plantar surface of heel.

D. Obtain puncture over back of heel.

E. Obtain puncture in the scalp on infants. Ans: ABC 13. A nurse is preparing to obtain a blood sampling from a CVAD? Which method should the nurse use when obtaining blood? (Select all that apply.)

A. The flushing method B. The aspiration method C. The mixing method D. The push-pull method E. The discard method Ans: CDE

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14. The nurse needs blood drawn per orders from a client with suspected sepsis. Which steps are utilized in the process of the evacuated tube system? (Select all that apply.)

A. Verify orders from healthcare provider.

B. Explain procedure to client.

C. Perform hand hygiene.

D. Attach vacutainer to venipuncture site needle.

E. Fill tubes halfway and invert twice upon removal. Ans: ABCD 15. What does the nurse have to take into consideration with clients when determining use of capillary puncture versus other types of blood collection? (Select all that apply.)

A. Unsuccessful venipunctures B. Needle phobias C. Vein accessibility D. Manufacturer preference E. Amount of blood required Ans: ABCE 16. Additives are often used to prevent blood clotting of blood samples after blood collection.

Which anticoagulants are the most common? (Select all that apply.)

A. Oxalates B. Citrates C. Heparin D. Warfarin E. EDTA Ans: ABCE 17. The nurse has orders to start an infusion of ½ NS on a diabetic client who is dehydrated. The nurse should immediately remove the venipuncture needle when the client reports which sign?

(Select all that apply.)

A. Extreme pain B. Numbness of the arm C. Electric shock sensation D. Blindness E. Referred abdominal pain Ans: ABC 18. The nurse is taking care of a client diagnosed with sepsis who has a series of blood tests ordered. What are the complications associated with venipuncture for blood cultures? (Select all that apply.)

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D. Erythema E. Vein damage Ans: ABCE 19. The nurse is collecting blood from an infant. Prior to collection what must the nurse do to prevent harm? (Select all that apply.)

A. Calculate 10% of the infant’s monthly blood volume.

B. Calculate 3% of blood volume per collection.

C. Determine oral sucrose levels.

D. Provide venipuncture to superficial veins.

E. Restrain infant in a blood drawing chair. Ans: AB

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Chapter 8: Complications of Infusion Therapy: Peripheral and Central Vascular Access Devices Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A nurse is preparing to assist a physician with the insertion of a peripherally inserted central catheter (PICC). The physician intends to use a guidewire insertion technique to insert the catheter. Which is an adjunct to guidewire insertion technique for a PICC? a. Laser b. Breakaway needle c. Surgical cutdown d. Fluoroscopy 2. A nurse aspires to be able to use and manage peripherally inserted central catheters (PICCs) in the home-care environment. For the nurse to safely and legally perform this function, the nurse must: a. hold a current license from the state. b. be trained in a state-approved agency and show proficiency in catheter insertion and maintenance. c. be a registered nurse (RN), meet minimal educational requirements, have employer-granted certification, and demonstrate evidence of competency. d. be an RN or licensed practical nurse and meet minimum stateapproved educational requirements.

3. A nurse using a pair of scissors to remove a dressing over a tunneled catheter cuts into the catheter.

Which should the nurse use to repair the catheter? a. Any universal repair kit b. A blunt-end needle and an injection cap system c. The manufacturer’s repair kit d. None. The nurse should notify the physician, because nurses do not repair central venous catheters.

4. A nurse specialist is preparing to insert a peripherally inserted central catheter (PICC).Which site is best for the insertion of the PICC? a. Basilic vein b. Innominate vein c. Subclavian vein d. Internal jugular vein 5. A nurse specialist is preparing to insert a peripherally inserted central catheter (PICC).

Complications related to the insertion of PICCs include: a. bleeding, malposition of the catheter, and nerve damage. b. phlebitis, infection, and SVC syndrome. c. thrombosis, pinch-off syndrome, and infection. d. septicemia, twiddler’s syndrome, and thrombosis.

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6. An oncology nurse prepares to flush a central venous catheter (CVC) prior to the administration of chemotherapy. When irrigating a CVC, the barrel capacity of the syringe should be a minimum of: a. 1 mL.

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b. c. d.

3 mL. 5 mL. 10 mL.

7. A nurse is to draw a blood sample for laboratory analysis from a multilumen central venous catheter.

When performing this procedure, which step should the nurse take first? a. Clean the port of the lumen with alcohol and allow it to dry. b. Flush blood out of the pigtail or cap following the procedure. c. Turn off infusates containing glucose or electrolyte for a full 1 minute prior to the blood draw. d. Flush the lumen with sodium chloride after the sample is obtained.

8. A nurse is preparing to assist with the insertion of a Groshong catheter. The nurse refers to the instructions regarding the use of Groshong catheters in a nursing reference book. The nurse learns that Groshong catheters differ from other central venous catheters in that they: a. have an open-ended tip with a three-position valve that stays open all the time. b. have a chemical makeup that allows for minimal use of heparin for flushing. c. have a closed-end tip with a three-position pressure-sensitive valve that stays closed when not in use. d. are available only in single-lumen type.

9. A nurse is changing a client’s PICC dressing. When changing a PICC dressing, the old dressing should be detached from the: a. distal to the proximal edge. b. proximal to the distal edge. c. side first, then from top to bottom. d. side first, then from bottom to top.

10. The PICC team is scheduled to remove a PICC before client discharge. Assessment of the catheter indicates the PICC and determines that the PICC is “stuck.” The most common cause of a stuck PICC is: a. phlebitis. b. vasospasm. c. thrombophlebitis. d. a catheter tear or rupture.

11. A nurse is to change the needleless injection cap of a multiple-lumen central line. Which techniques should be used by the nurse to change the injection cap? a. Hold the connector above the client’s heart and change the cap. b. Hold the connector below the client’s heart and change the cap. c. Hold the connector below the client’s heart, clamp, and change the cap. d. Hold the connector above the client’s heart, have the client hold his or her arms up, and change the cap.

12. A nurse, assisting a physician with the insertion of a central venous catheter, instructs a client to perform the Valsalva maneuver during the insertion of the catheter. The purpose of instructing the client to perform the Valsalva maneuver is to: a. make PICC insertion easier.

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b. c. d.

prevent thrombus formation. prevent air from entering the circulation. prevent malposition of the catheter during insertion.

13. A nurse has given instructions to a client being discharged home with a PICC, but evaluates that the client does not fully understand the instructions when the client states that he or she will: a. keep a repair kit in the home, if needed. b. wear a medical identification tag or bracelet. c. protect the insertion site when he or she is bathing. d. keep his or her activity level to a minimum while the catheter is in place.

14. A nurse attends a class on the care of multilumen central venous catheters. The nurse clearly understands the information presented in the class when, on performance evaluation, the nurse discards and replaces the injection cap on a multilumen catheter: a. no more frequently than every 72 hours. b. at the change of each shift. c. after administration of each medication. d. whenever blood was drawn from the lumen.

Multiple Response Identify one or more choices that best complete the statement or answer the question.

1. A nurse is preparing to assist with the insertion of a valved nontunneled central venous catheter (CVC). Which facts about a valved CVC should the nurse understand? SELECT ALL THAT APPLY. a. It is associated with more complications including occlusions from clots or fibrin. b. It operates by a pressure-activated two- or three-way slit. c. Its tip decreases adherence of platelets or fibrin. d. It does not require clamping.

2. A nurse is preparing to assist a physician with the insertion of an implanted catheter. Which are acceptable sites for insertion of an implantable catheter? SELECT ALL THAT APPLY. a. Peritoneum b. Intra-arterial c. Right subclavian d. Right atrium 3. A nurse is discharging a client with a new PICC. Which instructions should the nurse provide to the client regarding the management of the PICC dressing? SELECT ALL THAT APPLY. a. Change the dressing after the first 24 hours. b. Change the dressing every 10 days. c. Inspect the catheter insertion site for redness, swelling, and drainage. d. Use care not to dislodge the catheter during the dressing change. e. Place a recommended transparent dressing after the first 24 hours.

4. Which statements should a nurse include when explaining the advantages of a PICC to a client?

SELECT ALL THAT APPLY. a. The PICC is very reliable.

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b. c. d.

The PICC is cost effective.

The PICC is ideal for short-term use.

The PICC involves less pain and discomfort because of its multiple uses.

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Chapter 8: Techniques for Initiation and Maintenance of Central Vascular Access Answer Section MULTIPLE CHOICE 1. ANS: B The breakaway needle technique involves venipuncture made with an introducer needle. The catheter, with or without a guidewire, is threaded through the introducer. Fluoroscopy and surgical cutdown techniques are not used with PICC insertions.

PTS: 1 KEY: Cognitive Level: Application 2. ANS: C The Infusion Nurses Society (INS) supports the standard that a licensed physician or licensed RN, as determined by state regulations, who is educated and has demonstrated competency can insert a PICC. The RN should complete an educational program for PICC insertion.

Reference: Infusion Nurses Society. (2011). Infusion standards of practice. Journal of Infusion Nursing, 34(1S), S11.

PTS: 1 KEY: Cognitive Level: Application 3. ANS: C A sterile repair kit, specific to the type of catheter, should be readily available. Repairing the external portion of a tunneled catheter should be a sterile procedure that requires surgical gloves, a mask, and a cap.

PTS: 1 KEY: Cognitive Level: Application 4. ANS: A The peripheral veins in the antecubital fossa are the usual sites for PICC access. The basilica vein is larger than the cephalic and passes upward in a smooth path along the inner side of the biceps muscle, terminating in the axillary vein.

PTS: 1 KEY: Cognitive Level: Application 5. ANS: A Bleeding, malposition, and nerve damage can occur during insertion. All other combinations of complications are postinsertion.

PTS: 1 KEY: Cognitive Level: Application 6. ANS: D A 10- to 20-mL syringe barrel must be used to maintain a psi of approximately 7. The catheter burst pressure is 25 to 40 psi. The psi exerted by a 1-mL syringe is greater than 300, and that exerted by a 3-mL syringe is greater than 25. Use a push–pause technique.

PTS: 1 KEY: Cognitive Level: Application 7. ANS: C The nurse should first turn off infusates containing glucose or electrolytes 10 minutes before the blood draw so the blood sample will not be contaminated with these solutions.

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8. ANS: C The Groshong catheter is constructed with a two-way valve placed near the distal end, which restricts backflow of blood but can be purposefully overridden to obtain venous blood samples.

The valve eliminates the need for flushing with heparin.

PTS: 1 KEY: Cognitive Level: Application 9. ANS: A When removing a PICC dressing, detach it from the lower part toward the shoulder while securing the catheter. This action prevents inadvertent removal of the catheter from its position in the vein. Reference: Phillips, L. D., & Gorski, L. (2014). Techniques for initiation and maintenance of central vascular access. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.).

Philadelphia, PA: F.A. Davis.

10.

11.

12.

PTS: 1 KEY: Cognitive Level: Application ANS: B Vasospasm is usually secondary to mechanical or chemical irritation and ensues after the initiation of catheter removal, when movement of the catheter irritates the intima of the vein.

Other causes that hinder catheter removal are phlebitis, thrombophlebitis, valve inflammation, a knotted catheter, or endotheliosis of the catheter tip along the vein wall.

Reference: Phillips, L. D., & Gorski, L. (2014). Techniques for initiation and maintenance of central vascular access. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.).

Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application ANS: C The fluid level in the catheter drops when the catheter connector is held above the level of the client’s heart and opened to air. To prevent a drop in fluid level and entry of air into the system while changing injection caps, it is important to clamp and hold the connector below the level of the client's heart before removing the injection cap.

Reference: Phillips, L. D., & Gorski, L. (2014). Techniques for initiation and maintenance of central vascular access. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.).

Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application ANS: C Intrathoracic pressure changes allow for pulmonary ventilation that is responsible for air emboli associated with central lines. Pressure in the central veins decreases during inspiration and increases during expiration. If an opening into the central vein exposes the vessel to the atmosphere during the negative inspiratory cycle, air can be sucked into the central venous system in much the same manner that air is pulled into the lungs. The Valsalva maneuver stops the negative inspiratory cycle. Reference: Phillips, L. D., & Gorski, L. (2014). Techniques for initiation and maintenance of central vascular access. In Manual of I.V. therapeutics: Evidencebased infusion therapy (6th ed.).

Philadelphia, PA: F.A. Davis.

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The client should be taught that there are only minor activity restrictions with this catheter. He or she should protect the site during bathing and should wear or carry medical identification. The client should also have a repair kit in the home for PRN use, depending on the time length of the catheter. Reference: Phillips, L. D., & Gorski, L. (2014). Techniques for initiation and maintenance of central vascular access. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.).

Philadelphia, PA: F.A. Davis.

14.

PTS: 1 KEY: Cognitive Level: Application ANS: A The Centers for Disease Control and Prevention guidelines state that needless components should be changed as frequently as the administration sets or no more frequently than every 72 hours.

Reference: O’Grady, N., Alexander, M., & Burns, L.A. et al. (2011). Guidelines for the prevention of intravascular catheter-related infections. Atlanta, GA: Centers for Disease Control and Prevention.

PTS: 1

KEY: Cognitive Level: Application

MULTIPLE RESPONSE 1. ANS: B, C, D The smooth design and two- or three-way slit valve at the distal end and lack of rough edges on the tip decrease adherence of platelets. Clamping can increase pressure; therefore, clamping is not required.

PTS: 1 KEY: Cognitive Level: Application 2. ANS: A, B, C The peritoneum, intra-arterial, and subclavian are sites used for the delivery of medication. The right atrium is not a site for any catheter.

PTS: 1 KEY: Cognitive Level: Application 3. ANS: A, C, D, E A small amount of bleeding at the insertion site occurs during the first 24 hours after placement, so the original dressing must be replaced with a new one that can remain in place up to 7 days.

As with any IV site, inspection of the site is important. Because the catheter is not sutured in place, care should be taken during the dressing change not to dislodge the catheter. An occlusive transparent dressing is recommended for frequent inspection of the site.

Reference: Phillips, L. D., & Gorski, L. (2014). Techniques for initiation and maintenance of central vascular access. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.).

Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 4. ANS: A, B, D The PICC is indicated for clients who require long-term catheter placement (more than 1 month to 1 year). It is cost effective because the catheter does not need routine replacement, as P a g e 89 | 132

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peripheral IV catheters do. This catheter is more comfortable (only minimal discomfort is present), reliable, and has flexibility because of its multiple uses.

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Reference: Phillips, L. D., & Gorski, L. (2014). Techniques for initiation and maintenance of central vascular access. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.).

Philadelphia, PA: F.A. Davis.

PTS: 1

KEY: Cognitive Level: Application

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Chapter 9: Complications of Infusion Therapy: Peripheral and Central Vascular Access Devices Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A nurse is assisting in the placement of a client’s central venous catheter. The nurse is aware that the major complication that can occur during placement of a central venous access device is: a. phlebitis. b. infiltration. c. fibrin sheath formation. d. intravascular and extravascular malpositioning.

2. A nurse is caring for a client who has a newly implanted port. For which complication, specifically associated with implanted ports, should the nurse observe? a. Air embolus b. Occlusion c. External catheter breakage d. Displacement of the septum 3. A nurse is caring for a client who has lipid deposits occluding his or her central line.

Which declotting agent should the nurse use to clear lipid deposits from a central line? a. 70% ethanol b. Hydrochloric acid c. Sodium bicarbonate d. Alteplase (Activase) 4. A client complains to a nurse that his or her I.V. site is “sore.” The nurse notes that the site is red and edematous, but there is no palpable cord or streak. Using the criteria for infusion phlebitis, what should the nurse document as the severity of this phlebitis? a. 1+ b. 2+ c. 3+ d. 4+ 5. A nurse in an intensive care unit is caring for a client who has lipid deposits in her central line. Which agent should the nurse select to instill into the catheter in an attempt to dissolve the lipid deposits? a. Alteplase b. 70% ethanol c. Sodium bicarbonate d. 0.1% hydrochloric acid 6. A nurse in an intensive care unit is caring for a client who has an intraluminal obstruction of central line due to a thrombotic occlusion. Which declotting agent should the nurse select to remove the blood clots from a central line? a. Alteplase b. 70% ethanol c. Sodium chloride P a g e 92 | 132

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d.

Sodium bicarbonate

7. A nurse assesses that a client has developed 2+ phlebitis at the site of a current peripheral I.V. infusion. Which action should be the nurse’s first priority? a. Notify the physician. b. Start a new line proximal to the old site. c. Discontinue the I.V. catheter at that site. d. Apply warm moist packs to the existing I.V. site.

8. A nurse priming an I.V. administration set uncaps the distal end to attach a needleless device.

Before attachment, the administration set falls and hits the countertop. Which action should be taken by the nurse? a. Attach a new needleless device. b. Change the administration set. c. Wipe the tubing port with povidone-iodine. d. Scrub the needleless device with an alcohol swab.

9. A nurse assesses the insertion site of a peripheral I.V. catheter and notes that the site is red, warm to touch, and slightly edematous proximal to the I.V. cannula. The client reports discomfort when the site is touched. The nurse should interpret that these signs are most likely due to: a. phlebitis. b. a venous spasm. c. hypersensitivity to the I.V. solution. d. infiltration of the solution into the surrounding tissues.

10. A client who has a central venous tunneled catheter for administration of chemotherapy presents to a hospital with a fluctuating fever, hypotension, profuse sweating, nausea, and explosive diarrhea.

Based on this information, which condition should a nurse suspect? a. Local infection b. Septicemia c. Phlebitis at the infusion site d. Superior vena cava syndrome 11. A nurse assesses a client who is receiving an intermittent I.V. infusion of vancomycin hydrochloride.

The nurse notes that the I.V. site is warm, edematous, and indurated. The nurse also observes red streaking of the skin, peau d’orange skin, and vesicles. Based on this information, which condition should the nurse suspect? a. Occlusion b. Septicemia c. Extravasation d. Thrombophlebitis 12. A client who has been discharged from a hospital for 48 hours reports pain at a previous infusion site. On inspection of the site, a nurse finds redness and tenderness along the vein. Which condition should the nurse suspect? a. Extravasation b. Speed shock c. Bacterial phlebitis P a g e 93 | 132

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d.

Postinfusion phlebitis

13. A nurse is caring for multiple clients with I.V. access devices. The nurse carefully assesses each client for signs of local complications. For which systemic complication should the nurse observe? a. Phlebitis b. Hematoma c. Speed shock d. Extravasation 14. A nurse suspects that a client with a peripheral access device is experiencing a venous spasm.

Which report by the client should prompt the nurse to suspect this condition? a. Redness along the vein b. Cold feeling in the extremity c. Sharp pain extending from the site of infusion d. Increased temperature at the peripheral infusion site 15. Which complication of I.V. therapy should a nurse suspect if a client has a fluctuating fever, chills, malaise, tachycardia, tachypnea, hypotension, and altered mental status? a. Septicemia b. Local infection c. Thrombophlebitis d. Inflammatory response syndrome 16. Upon inspection of a client’s peripheral I.V. site, a nurse notes 2+ phlebitis of the client’s vein.

Which action by the nurse is most appropriate? a. Watch the site and document observations. b. Flush the cannula with 0.9% sodium chloride. c. Discontinue the cannula and apply heat to site. d. Leave the cannula in place and apply heat to the site.

Multiple Response Identify one or more choices that best complete the statement or answer the question.

1. Upon inspection of a client’s peripheral I.V. site, a nurse notes 3+ phlebitis of the client’s vein.

Which action by the nurse is most appropriate? SELECT ALL THAT APPLY. a. Watch the site and document observations. b. Discontinue the cannula and apply cold to the site initially for approximately 30 to 45 minutes. c. Elevate extremity slightly. d. Apply warm compresses after 30 to 45 minutes.

2. A nurse on a medical-surgical unit is caring for multiple clients. Which clients should the nurse monitor closely for signs of phlebitis because they are at increased risk? SELECT ALL THAT APPLY. a. Client with burns b. Client who is immunosuppressed c. Clients receiving total parenteral nutrition (TPN) P a g e 94 | 132

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3. A nurse attempts to withdraw a blood sample for laboratory analysis from a central venous catheter (CVC) and is unsuccessful due to an aspiration occlusion. What could potentially be causes of an aspiration occlusion? SELECT ALL THAT APPLY. a. Catheter migration b. A fibrin tail extending from the catheter tip c. The catheter tip being pressed up against the vein wall d. Chylothorax

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Chapter 9: Complications of Infusion Therapy: Peripheral and Central Vascular Access Devices Answer Section MULTIPLE CHOICE 1. ANS: D Central venous catheter tips can migrate during insertion; thus, both intravascular and extravascular malpositioning have been reported. Extravascular malpositioning can occur when the introducer slips out of the vein and the catheter is passed into the pleural space or the mediastinum.

Intravascular malpositions are more common. The catheter may coil in the vessel and advance into the right atrium or one of the smaller venous tributaries.

Reference: Phillips, L. D., & Gorski, L. (2014). Complications of infusion therapy: Peripheral and central vascular access devices. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 2. ANS: D Implanted ports have a septum, which is also called port migration. The port is sutured but can move out of position if the sutures become loose or if the client’s hand manipulates the port. Air embolus and occlusion can occur with a central venous device. External catheter breakage is specifically related to peripherally inserted central or tunneled catheters.

Reference: Phillips, L. D., & Gorski, L. (2014). Complications of infusion therapy: Peripheral and central vascular access devices. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 3. ANS: A Nonthrombotic occlusions are caused by mineral and fat precipitates. Seventy percent ethanol is used for lipid occlusions. Hydrochloric acid is indicated for mineral deposits. Sodium bicarbonate is effective for drugs with a high pH to restore patency. Alteplase is used for thrombotic occlusions.

Reference: Phillips, L. D., & Gorski, L. (2014). Complications of infusion therapy: Peripheral and central vascular access devices. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 4. ANS: B Phlebitis is an inflammation of the vein in which the endothelial cells of the venous wall become irritated and cells roughen, allowing platelets to adhere and predispose the vein to inflammationinduced phlebitis. The Infusion Nursing Society Standards of Practice phlebitis scale is as follows: 0 is no signs of phlebitis; 1+ is erythema at the site with or without pain; 2+ is pain at the site, erythema, or edema; 3+ includes all of the previous symptoms, as well as streak formation and palpable cord; 4+ includes all with palpable venous cord greater than 1 inch and purulent drainage. Reference: Infusion Nurses Society. (2011). Infusion Nursing Standards of Practice.

Journal of Infusion Nursing, 34(1S), S65.

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PTS: 1 5. ANS: B

KEY: Cognitive Level: Application

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The buildup of lipid residue within the catheter lumen or port reservoir may cause sluggish flow or total obstruction. The lipid residue can be dissolved with 70% solution of ethanol.

PTS: 1 KEY: Cognitive Level: Application 6. ANS: A Alteplase (rt-PA) is the only thrombolytic agent approved by the U.S. Food and Drug Administration for treatment of catheter thrombolytic occlusions. The other choices are used to dissolve specific nonthrombolytic occlusions.

PTS: 1 KEY: Cognitive Level: Application 7. ANS: C The nurse should immediately discontinue the I.V. at the phlebitic site and apply warm moist compresses to the area to speed resolution of the inflammation. The nurse should then restart the infusion, if possible, in the other extremity. The Infusion Nurses Society (INS) has a standard phlebitis scale of 0, 1+, 2+, and 3+. The physician is usually notified when there is 3+ phlebitis.

PTS: 1 KEY: Cognitive Level: Analysis 8. ANS: B The nurse should change the administration set because of contamination that could result in systemic infection for the client. Wiping the port with povidone-iodine is insufficient and would be contraindicated because the catheter will be attached directly to a catheter in the client’s vein.

The needleless device has not been contaminated and does not need replacement. Cleansing would not be indicated because the device is still sterile.

PTS: 1 KEY: Cognitive Level: Analysis 9. ANS: A Phlebitis at the I.V. site can be distinguished by client discomfort at the site, as well as by redness, warmth, and swelling proximal to the catheter. The line should be discontinued and a new line should be inserted at a different site.

10.

11.

PTS: 1 KEY: Cognitive Level: Analysis ANS: B The nurse should suspect that the client is experiencing septicemia. Signs and symptoms include a fluctuating fever, tremors, a profuse cold sweat, nausea and vomiting, explosive diarrhea, abdominal pain, and tachycardia. Septicemia is related to poor aseptic technique and contaminated equipment. Central venous access devices are at high risk for septicemia. Local infection and phlebitis are local complications that do not usually cause systemic signs and symptoms. Superior vena cava syndrome is related to central venous access. Signs and symptoms of this syndrome include progressive shortness of breath, dyspnea, cough, unilateral edema, and engorgement of the jugular, temporal, and arm veins.

PTS: 1 ANS: C

KEY: Cognitive Level: Analysis

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The nurse should suspect extravasation of the I.V. site. The term extravasation refers to the infiltration of vesicant medication into the tissue. A vesicant solution is a fluid or medication that causes the formation of blisters. Signs and symptoms of extravasation include reports of pain or burning by the client, skin tightness at the venipuncture site, blanching and coolness of the skin, slowed or stopped infusion, dependent edema of the affected extremity, and peau d’orange skin. Immediate intervention is necessary.

12.

13.

14.

15.

16.

PTS: 1 KEY: Cognitive Level: Application ANS: D Postinfusion phlebitis is associated with inflammation of a vein that usually becomes evident within 46 to 96 hours after the cannula has been removed. Factors that contribute to the development of phlebitis are the cannula insertion technique and dwell time, condition of the vein used for infusion, and type and compatibility of either the fluids or the medications used.

PTS: 1 KEY: Cognitive Level: Analysis ANS: C Speed shock is a systemic complication associated with rapid introduction of medication or fluid into the circulatory system. Hematoma, phlebitis, and extravasation are local complications of I.V. therapy.

PTS: 1 KEY: Cognitive Level: Application ANS: C Because of the spasm of the vein wall, sharp pain is the first symptom. Apply warm compress to relieve the spasm if possible, and continue the infusion once the spasm has subsided.

PTS: 1 KEY: Cognitive Level: Application ANS: A These symptoms are of a systemic complication. Septicemia is a serious systemic complication of infusion therapy. All the other responses are local complications.

PTS: 1 KEY: Cognitive Level: Application ANS: C All phlebitis, whether stage 1+ or 4+, must have the cannula removed to prevent further intima damage.

PTS: 1

KEY: Cognitive Level: Application

MULTIPLE RESPONSE 1. ANS: B, C, D The nurse should treat the suspected phlebitis by removing the cannula and restarting a cannula in a new I.V. site if appropriate. The nurse should then apply cold compresses to the affected site. Cold significantly decreases intradermal skin toxicity if applied for 45 minutes.

Reference: Phillips, L. D., & Gorski, L. (2014). Complications of infusion therapy: Peripheral and central vascular access devices. In Manual of I.V. therapeutics: Evidence- based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

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PTS: 1 KEY: Cognitive Level: Application 2. ANS: A, B, D Clients who are immunosuppressed or have massive loss of skin integrity are at risk for complications related to infusion therapy. Clients who have frequent I.V. manipulations are at risk for local complications as well. Clients receiving TPN are receiving the therapy via central line and phlebitis is of lower risk.

Reference: Phillips, L. D., & Gorski, L. (2014). Complications of infusion therapy: Peripheral and central vascular access devices. In Manual of I.V. therapeutics: Evidence- based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 3. ANS: A, B, C The other three answers cause catheter occlusion. Chylothorax is lymph fluid that has entered the pleural cavity as a result of transaction of the thoracic duct on the left side. Chyle is a milklike substance.

PTS: 1

KEY: Cognitive Level: Application

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Chapter 10: Infusion Medication Safety, Methods, and Routes Multiple Choice Identify the choice that best completes the statement or answers the question.

1. An oncologist orders an antineoplastic agent to be delivered to a client via the intraperitoneal route.

Intraperitoneal delivery of antineoplastic therapy delivers the drug directly into: a. an artery. b. a cavity. c. a vein. d. a ventricle.

2. A trauma physician orders an intraosseous (IO) infusion for an 8-year-old child. A nurse uses the EZ- IO to insert the IO infusion knowing that intraosseous infusions are used for: a. home antibiotic therapy. b. long-term nutritional support in children. c. delivery of fluids, electrolytes, and medications to children and adults when venous access is not attainable. d. delivery of fluids and medications only to children younger than 6 years old.

3. A committee is asked to investigate ways to reduce needlestick injuries in a hospital.

Which technology best assists in the reduction of needlestick injuries? a. Luer locks b. Elastomeric pumps c. Needleless systems d. Three-way stopcocks 4. A nurse is about to administer an I.V. push medication through a locking device. Which action should the nurse take with the nondominant hand while piercing the resealable lock port with the dominant hand? a. Hold a watch that has a second hand. b. Stabilize the port of the locking device. c. Wipe the insertion site with an alcohol swab for 15 seconds. d. Apply pressure over the catheter insertion site.

5. A physician’s assistant orders two medications for a client and instructs a nurse to administer the medications together. The nurse questions the order because incompatibilities can occur when two drugs are compounded. These incompatibilities may include: a. intermittent, physical, and biotransformation incompatibilities. b. drug interaction, synergism, and tolerance. c. physical, chemical, and therapeutic incompatibilities. d. anaphylaxis, tolerance, and drug interactions.

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b.

Causes speed shock, rapid onset of drug action, and allows for the absorption of

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drugs in gastric juices c. Prevents errors in compounding of medication, whereas there is a low risk for infiltration and phlebitis d. Allows for uninterrupted control of the medication rate, whereas there is a low risk for adverse effects and adsorption 7. A nurse is performing wound care on a client’s epidural site. Which is contraindicated for use when caring for epidural catheters? a. Povidone-iodine b. Sodium chloride solution c. Preservative-free medications d. Alcohol 8. A nurse is ordered to administer an I.V. medication at scheduled intervals over a period of time.

The nurse understands that after administering the medication, peak plasma concentration occurs: a. immediately. b. between doses or halfway between doses. c. just before the next dose is given. d. within 30 to 60 minutes after administration of the drug.

Multiple Response Identify one or more choices that best complete the statement or answer the question.

1. A pediatrician orders an intraosseous infusion for a 4-year-old child. A nurse obtains informed consent from the child’s parents after verifying that they understand the potential for which complications? SELECT ALL THAT APPLY. a. Cellulitis b. Air embolus c. Osteomyelitis d. Damage to the epiphyseal plate 2. A nurse is administering I.V. medications to multiple clients. Which are nursing responsibilities related to the administration of I.V. medications? SELECT ALL THAT APPLY. a. Altering dosages to achieve the desired drug response b. Determining the correct dose and route of administration c. Providing the client with education about the medication d. Recognizing both the desired and undesired effects of medication 3. A perioperative nurse is educating surgical clients on postoperative pain control. Which statements made by the nurse regarding PCA are true? SELECT ALL THAT APPLY. a. The best results for PCA occur when the client can administer a bolus every 5 to 10 minutes. b. The best results for PCA occur when the client can administer a bolus every 30 to 60 minutes. c. When clients are in control and know they can get more immediate pain relief by pushing a button, they are more relaxed. d. In the first 24 hours after surgery, the client has the greatest need for pain control.

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4. When preparing to piggyback an antibiotic to a primary I.V. infusion, a nurse could hang the medication in which of the following ways? SELECT ALL THAT APPLY. a. Hanging the antibiotic solution higher than the primary I.V. b. Hanging the antibiotic solution lower than the primary I.V. c. Hanging the antibiotic solution level to the primary I.V. and delivering simultaneously d. Disconnecting the main solution and plugging in the secondary administration set

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Chapter 10: Infusion Medication Safety, Methods, and Routes Answer Section MULTIPLE CHOICE 1. ANS: B Intraperitoneal drug administration deposits drugs directly into body cavities, such as the bladder, peritoneum, pleura, and pericardium. Regional routes include intra-arterial delivery of drugs into an artery and intraventricular routes into the ventricles.

Reference: Phillips, L. D., & Gorski, L. (2014). In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 2. ANS: C The route is limited to 24 hours.

PTS: 1 KEY: Cognitive Level: Application 3. ANS: C The needleless system has taken the place of 80% of needles used in I.V. therapy for piggyback, accessing ports, and accessing locking devices. Elastomeric pumps primarily deliver medications in the home-care environment. Luer locks help maintain integrity of connectors, and three-way stopcocks provide access options into the I.V. system. Stopcocks are add-on devices and should be used with caution because of the risk for contamination.

PTS: 1 KEY: Cognitive Level: Application 4. ANS: B The nurse should use the nondominant hand to stabilize the port of the locking device, which prevents the catheter from moving in the vein and possibly traumatizing the vein wall.

PTS: 1 KEY: Cognitive Level: Application 5. ANS: C Incompatibilities occur when two or more substances react or interact to change the normal activity of one or more components. Physical incompatibility, also called pharmaceutical incompatibility, occurs when one drug is mixed with other drugs or solutions to produce an unsafe product. Chemical incompatibility is defined as the reaction of a drug with other drugs or solutions that results in an alteration of the integrity and potency of the active ingredient.

Therapeutic incompatibility is an undesirable effect that occurs within a client, and as a result, there is either a decrease or an increase in therapeutic response.

PTS: 1 KEY: Cognitive Level: Application 6. ANS: A I.V. medications provide a route for substances that irritate the gastric mucosa, instant drug action when they are needed in an emergency, and control over the speed of delivery of the drug (e.g., can administer the drug slowly).

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Alcohol cannot be used on skin or near the dressing site because of the risk for migration of alcohol into the epidural space and the possibility of neural damage.

PTS: 1 KEY: Cognitive Level: Application 8. ANS: B Plasma concentration is measured by hourly intervals. The quantity of a given drug increases, reaches a peak plasma level (the time of maximum effect), and begins to decline steadily.

PTS: 1

KEY: Cognitive Level: Application

MULTIPLE RESPONSE 1. ANS: A, C, D Because of access into the bone, there is a potential for osteomyelitis and cellulitis; however, both have a low incidence of occurrence. Damage can also occur to the epiphyseal plate in the bone. Air embolus from this form of therapy is rare, because access to the circulation is via the medullary cavity.

Reference: Phillips, L. D., & Gorski, L. (2014). In Manual of I.V. therapeutics: Evidencebased infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 2. ANS: A, C, D The nursing process related to drug administration includes assessing for desired and undesired effects of the medication, planning and altering the plan to achieve the desired drug response in some situations (e.g., pain medication), and providing the client with education about the medication. The nurse is not responsible, in most situations, for determining the correct dose or route of medication administration.

Reference: Phillips, L. D., & Gorski, L. (2014). Infusion Medication, Methods & Routes. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 3. ANS: A, C, D For best results, the client should be able to administer a bolus of medication every 5 to 10 minutes, especially during the first 24 hours after surgery, when pain is greatest. Clients are also more relaxed when they feel in control and know they can get immediate pain relief when needed.

Reference: Phillips, L. D., & Gorski, L. (2014). Infusion Medication, Methods & Routes. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 4. ANS: A, C For intermittent infusion by the piggyback method, the primary I.V. bag can be placed lower than the piggyback medication. This type of placement allows gravity to assist in infusing the medication.

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There is a back check valve on most primary lines, which allows the primary infusion to resume once the piggyback medication has concluded. It is also important to correctly readjust the main drip rate after the secondary infusion is complete. The medication can be delivered simultaneously with primary solution; however, compatibility issues need to be addressed.

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Reference: Phillips, L. D., & Gorski, L. (2014). Infusion Medication, Methods & Routes. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1

KEY: Cognitive Level: Application

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Chapter 11: Transfusion Therapy Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A nurse has transfused a unit of packed RBCs, which has a 250-mL bag of 0.9% sodium chloride attached. The follow-up I.V. order is to hang a 1000-mL bag of 5% dextrose in water. Which steps should be taken by the nurse after completing the transfusion and initiating the next I.V. order? a. Aspirate the I.V. line before connecting the I.V. solution tubing. b. Infuse the remaining sodium chloride before attaching the new primary I.V. administration set. c. Flush the blood tubing with sodium chloride before changing to the primary I.V. administration set. d. Disconnect the tubing while there is blood in the line and attach the primary I.V. administration set.

2. A nurse obtains a blood specimen for type and cross match for a client suspected of having type A- positive blood. The nurse understands that A-positive blood contains which antibody in the plasma? a. Anti-A b. Anti-O c. Anti-B d. Anti-A and anti-B 3. A maternal-child nurse is caring for a client who has type A-negative blood, received no prenatal care, and delivered a type A-positive fetus. The nurse is concerned for the client because previous exposure to an antigen through pregnancy or transfusion may cause the client to develop: a. more antigens. b. an antibody to an antigen. c. tolerance to a transfusion. d. alloimmunization to the antibody.

4. A nurse is caring for a client diagnosed with thrombocytopenia. Thrombocytopenia is an abnormally low number of: a. platelets in the blood. b. antibodies in the blood. c. RBCs in the blood. d. white blood cells in the blood.

5. A client presents to a hospital laboratory wishing to make an autologous donation. An autologous donation is defined as the donation of: a. bone marrow to be used for transplant. b. blood by a donor to be used only by the donor. c. blood directly from one donor to a specified recipient. d. blood in a similar structure from a volunteer donor to a compatible recipient.

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6. A unit of packed red blood cells (PRBCs) is ordered for a client with anemia. The physician does not specify a rate for the infusion, according to standards of practice. Thus, the nurse should set the transfusion drip rate so that the PRBCs will be infused within:

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a. 1/2 hour. b. 1 hour. c. 2 hours. d. 4 hours.

7. A 25-year-old client who is a Jehovah’s Witness was recently diagnosed with multiple myeloma.

The client presents with a hemoglobin (Hgb) level of 6 g/dL. The client’s physician orders a transfusion of 4 units of red blood cells, but the client refuses. Which is the most appropriate action by a nurse? a. Do nothing. b. Administer the transfusion as ordered. c. Notify the physician of the client’s refusal. d. Convince the client to accept the transfusion.

8. A 90-year-old client is receiving 2 units of packed red blood cells. Furosemide (Lasix) 80 mg I.V. pyelography has been ordered after the first unit of blood has infused. The client asks a nurse why she is getting Lasix. The nurse’s response should be based on the understanding that furosemide: a. prevents pulmonary emboli. b. prevents circulatory overload. c. lowers the blood pressure. d. counteracts the transfusion-induced hypercalcemia.

9. A nurse is caring for a client diagnosed with post-transfusion hepatitis after a blood transfusion.

Which virus is the primary cause of post-transfusion hepatitis? a. Hepatitis A virus b. Hepatitis B virus c. Cytomegalovirus d. HIV 10. A physician orders 1 unit of packed red blood cells for a client diagnosed with anemia. A nurse correctly infuses the blood cells over a period of: a. 1 hour. b. 2 hours. c. 4 hours. d. 6 hours.

11. A nurse is preparing to administer a unit of packed red blood cells to a client. Which type of I.V. fluid should be used to facilitate the infusion of blood for this client? a. Lactated Ringer’s b. Normal saline c. 5% dextrose in water d. 5% dextrose and normal saline 12. A nurse is caring for a client who is experiencing thrombocytopenia secondary to chemotherapy.

Which laboratory test result would be consistent with thrombocytopenia from chemotherapy? a. Low white blood cell count b. Low platelet count c. Low red blood cell count P a g e 113 | 132

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13. A physician instructs a nurse to obtain a fluid warmer before implementing written orders for a client. The nurse obtains the fluid warmer knowing that it is used primarily for the administration of: a. parenteral nutrition (PN). b. solutions for the pediatric client. c. blood. d. solutions for the geriatric client.

Multiple Response Identify one or more choices that best complete the statement or answer the question.

1. A client is concerned about receiving donated blood for fear of contracting AIDS. A nurse reassures the client knowing that all transfusions are screened for which antibodies? SELECT ALL THAT APPLY. a. Syphilis b. HIV c. Surface hepatitis B d. Mononucleosis e. T-lymphotrophic virus 2. A nurse sends a client’s blood specimen to the laboratory for a type and crossmatch. For which antigens in the blood system should the laboratory check? SELECT ALL THAT APPLY. a. ABO blood groups b. Rh factor c. Immunoglobulin M (IgM) d. Human leukocyte antigen (HLA) 3. A nurse is ordered to perform a type and cross match on a client scheduled for surgery. During the “type and cross,” the laboratory technician tests the client’s blood for the presence of which antigens? SELECT ALL THAT APPLY. a. ABO b. HLA c. Rh d. IgM 4. A nurse is preparing to administer blood to a client. Before hanging a unit of blood, which information is a nurse responsible for verifying with another nurse? SELECT ALL THAT APPLY. a. ABO and Rh b. Client identification with two independent identifiers c. Donor unit number d. Expiration date e. Client room number 5. A physician orders an infusion of fresh frozen plasma (FFP) for a client. A nurse administers the infusion knowing that FFP is used for which purposes? SELECT ALL THAT APPLY. a. Platelet deficiencies b. Demonstrated factor deficiencies c. Warfarin sodium (Coumadin) drug reversal P a g e 115 | 132

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1.

A client who is to receive 4 units of whole blood has a hemoglobin (Hgb) level of 5 g/dL. A nurse should anticipate that the complete blood count after transfusion will reflect an Hgb of g/dL. Fill in the blank.

Chapter 11: Transfusion Therapy Answer Section MULTIPLE CHOICE 1. ANS: C When a unit of blood has finished infusion, the line should be flushed with approximately 20 to 30 mL sodium chloride before the blood administration set is taken down and the new primary administration set is connected.

Reference: Sink, B. (2008). Administration of blood components. In J. D. Roback, M. R. Combs, B. J. Grossman, & C. D. Hillyer (Eds.), Technical manual (16th ed.). Bethesda, MD: American Association of Blood Banking.

PTS: 1 KEY: Cognitive Level: Application 2. ANS: C An antigen is a substance capable of stimulating the production of an antibody and then reacting with that antibody in a specific way. The substances that can elicit an immunological response in the blood are the A and B antigens. Antibodies are found in the plasma or serum. Anti-B is the antibody in the plasma of a group A antigen.

Reference: Phillips, L. D., & Gorski, L. (2014). Transfusion therapy. Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 3. ANS: B An antigen is a substance capable of stimulating the production of an antibody and then reacting with that antibody in a specific way. If an Rh-negative mother is exposed to an Rh-positive fetus, the mother will build up antibodies in response to the D antigen exposure. After A and B, the most important RBC antigen is the D antigen.

Reference: Phillips, L. D., & Gorski, L. (2014). Transfusion therapy. Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 4. ANS: A Platelets are administered to control or prevent bleeding from platelet deficiencies that result in either thrombocytopenia or the presence of functionally abnormal platelets.

Reference: Phillips, L. D., & Gorski, L. (2014). Transfusion therapy. Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 5. ANS: B Autologous transfusion refers to the collection, storage, and delivery of a client’s own blood.

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salvage, (3) perioperative salvage or intraoperative deposit, (4) intraoperative salvage, and (5) postoperative salvage.

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Reference: Phillips, L. D., & Gorski, L. (2014). Transfusion therapy. Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 6. ANS: D Standards of practice dictate that if a physician has not ordered the rate, the transfusion must be completed within 4 hours. When a longer transfusion time is clinically indicated, the unit may be divided by the blood bank, and the portion that is not being transfused can be properly refrigerated. Reference: Sink, B. L. (2008). Administration of blood components. In J. D. Roback, M. R. Combs, B. J. Grossman, & C. D. Hillyer (Eds.), Technical manual (16th ed.). Bethesda, MD: American Association of Blood Banks.

PTS: 1 KEY: Cognitive Level: Application 7. ANS: C The physician should be notified that the client has refused the treatment. Treatment without the client’s consent is the most frequently alleged act of battery involving nurses. Doing nothing would constitute negligence.

PTS: 1 KEY: Cognitive Level: Analysis 8. ANS: B Diuretics, such as furosemide, may be administered to prevent or correct circulatory overload.

Furosemide may lower blood pressure, but this is not why it is administered to this client. It is not given to counteract hypercalcemia and does not prevent pulmonary emboli.

Reference: Sink, B. L. (2008). Administration of blood components. In J. D. Roback, M. R. Combs, B. J. Grossman, & C. D. Hillyer (Eds.), Technical manual (16th ed.). Bethesda, MD: American Association of Blood Banks.

PTS: 1 KEY: Cognitive Level: Application 9. ANS: B Viral hepatitis is still a serious risk in transfusion. With the current screening procedures, a recipient’s chance is 1 in 200,000 that a pint of blood may result in a non-A or non-B viral hepatitis. Currently, the risk of a transfusion-associated HIV infection is remote—no greater than 1 in 825,000. Reference: Eberhard, W., Fiebig, M. D., & Busch, M. P.(2008). Infectious disease screening. In J. D. Roback, M. R. Combs, B. J. Grossman, & C. D. Hillyer (Eds.), Technical manual (16th ed.).

Bethesda, MD: American Association of Blood Banks.

10.

PTS: 1 KEY: Cognitive Level: Application ANS: C American Association of Blood Banks (AABB) standards require that blood be infused within 4 hours because of warming of the blood at room temperature and increasing debris in the blood filter. Reference: Sink, B. L. (2008). Administration of blood components. In J. D. Roback, M. R. Combs, B. J. Grossman, & C. D. Hillyer (Eds.), Technical manual (16th ed.). Bethesda, MD: American Association of Blood Banks.

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0.9% sodium chloride (normal saline) is the only solution that is compatible with transfusion of blood according to AABB. Reference: Sink, B. L. (2008). Administration of blood components. In J. D. Roback, M. R. Combs, B. J. Grossman, & C. D. Hillyer (Eds.), Technical manual (16th ed.). Bethesda, MD: American Association of Blood Banks.

12.

13.

PTS: 1 KEY: Cognitive Level: Application ANS: B Thrombocytopenia is a deficiency in platelet or functionally abnormal platelets.

PTS: 1 KEY: Cognitive Level: Application ANS: C Specific equipment, called fluid or blood warmers, is available to warm blood, if needed.

Only temperature devices specifically designed to warm blood should be used for blood component therapy. PN, pediatric, and geriatric infusions are not routinely warmed.

PTS: 1

KEY: Cognitive Level: Application

MULTIPLE RESPONSE 1. ANS: A, B, C, E Transfusions are screened for bloodborne pathogens; mononucleosis is not a bloodborne pathogen. Reference: Eberhard, W., Fiebig, M. D., & Busch, M. P.(2008). Administration of blood components. In J. D. Roback, M. R. Combs, B. J. Grossman, & C. D. Hillyer (Eds.), Technical manual (16th ed.). Bethesda, MD: American Association of Blood Banks.

PTS: 1 KEY: Cognitive Level: Application 2. ANS: A, B The laboratory should test the client’s blood for ABO blood group and Rh factor. The HLA system, located on leukocytes, platelets, and most tissue cells, is screened before transplants or multiple transfusions. The IgM is one of the five different types of immunoglobulins in the blood.

Reference: Gebel, H. M., Pollack, M. S., & Bray, R. A. (2008). The HLA system. In J. D. Roback, M. R. Combs, B. J. Grossman, & C. D. Hillyer (Eds.), Technical manual (16th ed.). Bethesda, MD: American Association of Blood Banks.

PTS: 1 KEY: Cognitive Level: Application 3. ANS: A, B, C ABO, HLA, and Rh are all antigens present in human blood. IgM is an immunoglobulin, or immune antibody.

Reference: Phillips, L. D., & Gorski, L. (2014). Transfusion therapy. Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 4. ANS: A, B, C, D

KEY: Cognitive Level: Application

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The nurse’s responsibilities include blood product inspection; verification of client identification, product inspection, and expiration date; confirmation of compatibility between recipient and donor, and informed client consent; client education; and monitoring the client during and after administration. A client’s room number should never be used to verify the identification of a client. Reference: Sink, B. (2008). Administration of blood components. In J. D. Roback, M. R. Combs, B. J. Grossman, & C. D. Hillyer (Eds.), Technical manual (16th ed.). Bethesda, MD: American Association of Blood Banking.

PTS: 1 KEY: Cognitive Level: Application 5. ANS: B, C, D FFP is prepared from whole blood by separating and freezing the plasma within 6 hours of collection. FFP does not provide platelets and is primarily used to provide replacement coagulation factors. It is indicated for clients with multiple coagulation factor deficiencies.

Reference: Phillips, L. D., & Gorski, L. (2014). Transfusion therapy. Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1

KEY: Cognitive Level: Application

COMPLETION 1. ANS: 9 One unit of whole blood will raise an adult’s Hgb level by 1 g/dL and the hematocrit by about 3% to 4%. In a client with an Hgb level of 5 g/dL who is receiving 4 units of whole blood, the nurse should expect an Hgb level of 9 g/dL within 24 hours after the infusion.

Reference: AuBuchon, J. P. (2008). Hemotherapy decisions and their outcomes. In J. D. Roback, M. R. Combs, B. J. Grossman, & C. D. Hillyer (Eds.), Technical manual (16th ed.). Bethesda, MD: American Association of Blood Banks.

PTS: 1

KEY: Cognitive Level: Analysis

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Chapter 12: Parenteral Nutrition Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A nurse is reviewing the medical record for a client with a nursing diagnosis of Altered nutrition: Less than body requirements. Which assessment data is the best indicator for continued need of additional nutritional support? a. Intake and output b. Calorie count c. Serum electrolytes d. Trace element levels 2. A physician orders parenteral proteins for a client who is emaciated. A nurse orders the proteins from the pharmacy knowing that parenteral proteins are supplied as: a. synthetic crystalline amino acids. b. casein amino acids. c. immunoglobulins. d. albumin.

3. A physician orders a total nutrient admixture (TNA) solution for a client diagnosed with severe anorexia nervosa. A nurse administers the solution knowing that TNA consists of a combination of: a. platelets, plasma, and white blood cells. b. fats, carbohydrates, and proteins. c. fats, electrolytes, and trace elements. d. carbohydrates, proteins, and heparin.

4. A nurse is instructed to add heparin to a client’s TPN per a physician’s order. What is the purpose of adding heparin to a TPN solution? a. To enhance blood glucose levels b. To thin the TPN solution so that it easily infuses c. To decrease the incidence of subclavian vein thrombosis d. To prevent gastric ulcers 5. A clinical nurse specialist is conducting an in-service for critical-care nurses regarding the administration of cyclic TPN. Which key point should be included in the inservice? a. It is indicated for clients receiving continuous, stabilized TPN. b. It is indicated for short-term parenteral nutrition. c. It must be escalated to maintain rate d. The dose must be tapered to avoid abrupt changes in glucose levels.

6. A nurse is caring for a critically ill client who has been admitted to an intensive care unit. The nurse monitors the client’s nutritional status. During times of stress, which element of metabolism is radically altered? a. Protein b. Fat P a g e 123 | 132

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7. A nurse is caring for a client receiving TPN. In addition to multiple vitamins, which medication might be anticipated that the nurse administer intramuscularly on a weekly basis? a. Heparin 1000 units b. Vitamin K 5 mg c. Zinc 2.5 mg d. Biotin 60 mg 8. A client has a triple-lumen tunneled catheter and is receiving PN with daily infusions of lipids, as well as several other I.V. medications. How should a nurse infuse the lipids? a. Into an injection port separate from the TPN solution b. In the same line as the TPN, between the filter and the injection port c. In the same line as the TPN, between the filter and the TPN solution d. Using a 0.45-mm filter 9. A physician orders parenteral nutrition (PN) for a critically ill client. The client’s PN is administered through a central line because PN is: a. isotonic. b. hypertonic. c. hypotonic. d. atonic.

10. A physician orders total parenteral nutrition for a critically ill client. Which medication/supplement may be safely added to the client’s total parenteral solution? a. Regular insulin, heparin, and H2 inhibitors b. Iron, vitamin K, and cimetidine c. Iron, heparin, and neutral protamine Hagedorn (NPH) insulin d. Regular insulin, vitamin K, and H2 inhibitors 11. A client with pancreatitis has an order to receive parenteral nutrition with lipid infusions three times a week. The first transfusion of lipids is started slowly, but after a few minutes, the client reports back pain and becomes dyspneic. Which action should be taken by the nurse? a. Take the client’s vital signs. b. Stop the infusion of lipids and notify the physician. c. Give the client PRN pain medication and his bronchodilator. d. Discontinue the I.V. 12. A client is to receive peripheral parenteral nutrition. Which solutions can be administered peripherally? a. 20% dextrose and 8.5% amino acids b. 10% dextrose and 3.5% amino acids c. 50% dextrose and 7% amino acids d. 50% dextrose and 3.5% amino acids 13. A nurse is evaluating a client who has been receiving parenteral nutrition (PN). The nurse should identify a desirable client outcome of total PN therapy as: a. weight gain of 1/2 lb/day. b. capillary blood glucose level of 160 mg/dL. P a g e 125 | 132

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d.

serum cholesterol level 225 mg/dL.

14. A nurse prepares to hang an infusion of parenteral nutrition (PN). Which fluids can be given concurrently through the same I.V. administration set as the PN? a. Blood b. Platelets c. Intravenous piggyback medications d. Lipid emulsions 15. A nurse is caring for a client who is diagnosed with a fatty acid deficiency. Which order should the nurse anticipate receiving from a physician to correct this deficiency? a. Protein b. 10% dextrose c. Lipid emulsion d. Trace elements 16. A nurse is preparing to infuse a parenteral nutrition (PN) admixture. Which filter should be used with total nutrition admixtures (three-in-one)? a. 0.22 µm b. 1.0 µm c. 1.2 µm d. 170 µm has:

17. A nurse administers total parenteral nutrition (PN) to a client via a central catheter because PN a. An osmolarity equal to blood plasma. b. An osmolarity greater than 600 mOsm. c. An osmolarity less than 300 mOsm. d. A pH between 5 and 9.

Multiple Response Identify one or more choices that best complete the statement or answer the question.

1. A physician orders the peripherally inserted central catheter (PICC) team to insert a PICC for a client who is scheduled for chemotherapy. Which are advantages of PICCs? SELECT ALL THAT APPLY. a. Causes less body image disturbance b. Eliminates the pain of frequent venipunctures c. Decreases risk for pneumothorax and air embolism on insertion d. Preserves peripheral vascular system in the upper extremity 2. As part of a client’s health history, a nurse performs a nutritional assessment of the client. Which components should be included in the nurse’s nutritional assessment? SELECT ALL THAT APPLY. a. Dietary history b. Anthropometric measurements c. Physical examination d. Computerized tomography (CT) scan of the abdomen

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Chapter 12: Parenteral Nutrition Answer Section MULTIPLE CHOICE 1. ANS: B The best indicator of whether a client is taking in adequate oral nourishment following TPN is a calorie count. This gives an idea of the total calories consumed and the distribution of the client’s diet in terms of protein, fat, and carbohydrate. Intake and output is useful as a measure of fluid balance, and the laboratory studies previously identified give an indication of electrolyte balance. Reference: Ackley, B. J., & Ladwig, G. A. B. (2010). Nursing diagnosis handbook: An evidence- based guide to planning care (9th ed.). St. Louis, MO: Mosby Elsevier.

PTS: 1 KEY: Cognitive Level: Application 2. ANS: A Protein is a body-building nutrient that promotes tissue growth, repair, and the replacement of body cells. Parenteral proteins are elemental, providing a synthetic crystalline amino acid that does not cause an antigenic reaction.

Reference: Phillips, L. D., & Gorski, L. (2014). Parenteral nutrition. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 3. ANS: B TNA are systems that hold combinations of dextrose, amino acids, and fat emulsions in one container. It is also referred to as all-in-one or three-in-one.

Reference: Phillips, L. D., & Gorski, L. (2014). Parenteral nutrition. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 4. ANS: C Heparin doses of 100 to 300 units/L have been ordered to decrease the incidence of subclavian vein thrombosis.

Reference: Phillips, L. D., & Gorski, L. (2014). Parenteral nutrition. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 5. ANS: A Cyclic TPN is used for long-term stabilized clients. Cyclic TPN is not routinely used for short-term therapy, and after clients receive cyclic TPN, there is no need to escalate or taper doses, because the glucose response has been stabilized.

Reference: Phillips, L. D., & Gorski, L. (2014). Parenteral nutrition. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 6. ANS: C

KEY: Cognitive Level: Application

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The major purpose of carbohydrates is to provide energy. During the critical phase of illness or injury, carbohydrate metabolism is radically altered; thus, hyperglycemia is a hallmark of stress.

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Reference: Phillips, L. D., & Gorski, L. (2014). Parenteral nutrition. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 7. ANS: B Heparin, zinc, and biotin can be added to the TPN solution. Vitamin K cannot be administered intravenously, so it must be given intramuscularly.

Reference: Phillips, L. D., & Gorski, L. (2014). Parenteral nutrition. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 8. ANS: B Lipids should be run below the filter to prevent the removal of essential elements. Lipids should be run only through a special 1.2-mm lipid filter.

Reference: Phillips, L. D., & Gorski, L. (2014). Parenteral nutrition. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1 KEY: Cognitive Level: Application 9. ANS: B Solutions that provided total nutrients for the client must be administered through a central line because of the osmolarity of the solution. Solutions with dextrose percentages greater than 10% are hypertonic and must be administered by central line. Most PN contains 50% dextrose.

10.

11.

12.

13.

PTS: 1 KEY: Cognitive Level: Application ANS: A The only medications that can be added to nutritional support for compatibility are regular insulin, heparin, or an H2 inhibitor.

PTS: 1 KEY: Cognitive Level: Application ANS: B The nurse should stop the infusion of lipids and notify the physician because the client is having an adverse reaction to the lipids.

PTS: 1 KEY: Cognitive Level: Analysis ANS: B The solution of 10% dextrose and 3.5% amino acids may be administered peripherally. The other solutions must be administered through a central catheter because of the osmolarity of dextrose solutions greater than 10%.

PTS: 1 KEY: Cognitive Level: Application ANS: A Nutritional status should improve with total PN, as evidenced by a consistent weight gain.

Option 2 is incorrect because the normal blood glucose level should be between 60 and 120 mg/dL. Option 3 indicates hyponatremia. Option 4 indicates an elevated cholesterol value.

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Fat emulsions are administered concurrently with total PN (TPN) and are filtered with a special 1.2- mm filter. Blood and blood products should not be given through the same line as TPN because they could coat the inner lumen of the catheter, restricting flow of the TPN. Medications are not routinely administered concurrently with TPN because they could be incompatible.

15.

16.

17.

PTS: 1 KEY: Cognitive Level: Application ANS: C Fats are delivered by infusion as lipid emulsions.

PTS: 1 KEY: Cognitive Level: Application ANS: C When lipids are added to nutritional support or administered by piggyback, they must be filtered with a 1.2-µm filter because of the fat molecules of the solution.

PTS: 1 KEY: Cognitive Level: Application ANS: B Solutions that provided total nutrients for the client must be administered through a central catheter because of the osmolarity greater than 600 mOsm. Solutions with dextrose percentages more than 10% are hypertonic and must be administered by central catheter. Most TPN solutions contain 50% dextrose.

Reference: Infusion Nurses Society. (2011). Infusion Nursing Standards of Practice. Journal of Infusion Nursing, 34(S1), S91.

PTS: 1

KEY: Cognitive Level: Application

MULTIPLE RESPONSE 1. ANS: B, C, D The advantages of a PICC include eliminating the pain associated with frequent venipuncture, decreasing the risk for pneumothorax and air embolism, and preserving the peripheral vascular system of the upper extremities. Because PICCs are external, they do have potential for causing concerns for the client regarding body image.

PTS: 1 KEY: Cognitive Level: Application 2. ANS: A, B, C Dietary history, anthropometric measurements, and physical examination are all components of the nutritional assessment, along with medical and social history, energy tests, bone radiology tests, and laboratory tests. CT does not provide information needed for nutritional support.

Reference: Phillips, L. D., & Gorski, L. (2014). Parenteral nutrition. In Manual of I.V. therapeutics: Evidence-based infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis.

PTS: 1

KEY: Cognitive Level: Application

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