TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER
Chapter 28: Intravenous Therapy Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. After inserting a peripheral IV line into the patient, the nurse provides patient teaching about
the IV insertion site. What information does the nurse give to the patient? a. Expect minor pain at the insertion site. b. Report redness at the insertion site. c. Remain on bed rest with the IV infusion. d. Disconnect IV tubing to change a gown. ANS: B
The nurse instructs the patient to report redness at the insertion site for early detection of IV complications, including infection and phlebitis. The IV site should cause very little discomfort if the infusion is proceeding without problems. Pain associated with an IV infusion indicates vein irritation from infusing fluid, irritating medication, infiltration, extravasation, infection, or phlebitis. Patients with IV infusions are not confined to bed. The nurse instructs the patient to call for help when changing the gown because, if the gown has no snaps at the shoulder, the nurse must feed the IV tubing and bag through the opening of the gown when the gown is changed. DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation
OBJ: NCLEX: Physiological Integrity
2. The nurse is trying to access the best insertion site on a patient for IV therapy. Which
N
principle would the nurse use to achieve this goal? a. Avoid using soft, bouncy veins. b. Choose the patient’s best proximal vein. c. Choose a site large enough for adequate blood flow. d. Always use the smallest-gauge IV catheter available. ANS: C
The site must be large enough to prevent interruption of venous flow while allowing adequate blood flow around the catheter. The nurse chooses a site for venipuncture with soft, bouncy veins because these veins are more easily punctured and stabilized during the insertion. The most distal vein is the best for insertion to maintain the maximum number of potential sites for future use. The smallest-gauge IV catheter suitable for both the therapy and the patient’s vein should be selected, which may not be the smallest available. DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation
OBJ: NCLEX: Physiological Integrity
3. The health care provider’s order reads, “Administer 5% dextrose solution with normal saline
(D5NS) intravenously now.” What action does the nurse perform first? a. Infuse a bolus of D5NS to the patient now. b. Regulate an IV infusion pump at 125 mL/hr. c. Call the health care provider to clarify the order. d. Perform venipuncture with a butterfly needle.
TESTBANKWORLD.ORG
