Preview Extract
Chapter 22
1. A client’s peripheral intravenous catheter has infiltrated several times during an 8-hour
shift. The nurse realizes that the client needs a central venous access device. Which of the
following intravascular devices could a properly trained nurse insert under the guidelines of
the infusion nursing standards of practice?
Select all that apply.
1. A midline
2. A peripherally inserted central catheter
3. An implanted port
4. A triple-lumen catheter
5. A tunneled noncuffed catheter
Answer: 1. A midline
2. A peripherally inserted central catheter
Rationale:
A midline. This catheter can be inserted by nurses educated and skilled in the procedure. A
peripherally inserted central catheter. This catheter can be inserted by nurses educated and
skilled in the procedure. An implanted port. An implanted port is used for long-term therapy
and requires an operative procedure for insertion. A triple-lumen catheter. A triple-lumen
catheter is inserted by a physician. A tunneled noncuffed catheter. A tunneled noncuffed
catheter is used for long-term therapy and requires an operative procedure for insertion.
2. Which of the following nursing diagnoses would explain the purpose of the using a selfsheathing stylet catheter?
1. Risk for Injury
2. Risk for Fluid-Volume Deficit
3. Risk for Infection
4. Risk for Altered Nutrition
Answer: Risk for Injury
Rationale:
Risk for Injury is the nursing diagnosis that explains the purpose of the self-sheathing
catheter. It is engineered with a safety mechanism that causes the needle to become encased
in a protective chamber upon removal from the inserted catheter, thus preventing a needlestick injury. A self-sheathing stylet catheter use does not reflect fluid-volume status and is not
used to prevent infection. The use of a self-sheathing stylet catheter is not related to
nutritional status.
3. The nurse is preparing a client for discharge with an implanted port. Instructions for site
care would include:
1. No dressings are necessary.
2. Apply a sterile dressing every 2 days.
3. Place a clean bandage daily.
4. Apply a nonadhering dressing weekly.
Answer: No dressings are necessary.
Rationale:
No dressings are necessary because the port is completely under the skin. Using a sterile
dressing, nonadhering dressing, or a bandage is incorrect because no dressing is required.
4. A client receiving peripheral intravenous therapy is mobile but having difficulty
maneuvering the intravenous infusion pump. The nurse would choose which of the following
add-on devices to allow greater mobility for the client?
1. An extension set
2. A stopcock
3. A filter device
4. A multiflow adapter
Answer: An extension set
Rationale:
An extension set is a device that will add length to the existing administration set and allow
the client to move more freely without having to push the intravenous pump. A stopcock is
used to direct flow of an infusate and would not increase tubing length. A filter device
provides sterility to the infused parenteral medication or solution but does not increase the
tubing length. A multiflow adapter is used for the administration of two or more infusates
simultaneously and does not increase tubing length.
5. When the alarm of a client’s infusion delivery system sounds, the nurse would suspect
which of the following?
Select all that apply.
1. Air in the line
2. Infusion complete
3. Occlusion of the tubing
4. Low battery
5. Infusion infiltration
Answer: 1. Air in the line
2. Infusion complete
3. Occlusion of the tubing
4. Low battery
Rationale:
Air in the line. The infusion pump will detect the presence of air in the fluid pathway of the
set. Infusion complete. The preset volume limit has been reached, which sounds the alarm.
Occlusion of the tubing. Infusion pumps detect disruptions of flow above the catheter and
resistance to flow occurring below the device. Low battery. The alarm will sound if the pump
is requiring more power from being unplugged for client use. Infusion infiltration. The alarm
does not consistently sound for infiltration of an intravenous site; therefore, the intravenous
fluid may continue to infuse into the client’s tissue until the infiltration is severe enough to
reduce the rate of delivery.
6. The nurse is caring for a client with a closed head injury with increased intracranial
pressure. The nurse selects which method to obtain and monitor intracranial pressure
readings?
1. An intrathecal catheter
2. An intraspinal catheter
3. An intraosseous catheter
4. A arterial venous shunt
Answer: An intrathecal catheter
Rationale:
An intrathecal catheter is used to monitor intracranial pressure as well as drain cerebral spinal
fluid when intracranial pressure is increased. An intraspinal catheter is used for procedures
such as the delivery of anesthesia, diagnostic testing, and infusions. An intraosseous catheter
is inserted into the bones of the long legs or iliac crest and is used to treat thermal injuries,
trauma, cardiac arrest, or other life-threatening illnesses until the traditional vascular access
can be obtained. An arterial venous shunt is used to anastomose venous and arterial structures
often located in the arm for dialysis therapy.
7. Prior to initiating infusion therapy for a client, which of the following nursing diagnoses
would the nurse most likely incorporate into the plan of care?
Select all that apply.
1. Fluid-Volume Deficit
2. Risk for Infection
3. Alteration in Comfort
4. Impaired Gas Exchange
5. Ineffective Individual Coping
Answer: 1. Fluid-Volume Deficit
2. Risk for Infection
Rationale:
Fluid-Volume Deficit. Infusion therapy will directly reflect the client’s fluid volume and
electrolyte status. Risk for Infection. There are inherent risks associated with the invasive
nature of infusion therapy. Knowledge of infection control principles is essential for
minimizing and preventing complications from infection. Alteration in Comfort. There is
often minimal short-term discomfort to the client during insertion of the device for infusion
therapy. Impaired Gas Exchange. This does not reflect the purpose of infusion therapy and
reflects the respiratory status of the client. Ineffective Individual Coping. The client’s coping
does not reflect the reason that the client needs infusion therapy.
8. The nurse would initiate which of the following methods to facilitate drying of the
antiseptic solution applied to the intravenous site?
1. Allow the area to dry itself.
2. Fan the area.
3. Blow on the area.
4. Blot the area.
Answer: Allow the area to dry itself.
Rationale:
Allowing the area to dry itself is the infusion therapy standard of practice. Blowing, fanning,
or blotting the prepped area is contraindicated, as this would increase the risk of infection to
the site.
9. While flushing a central vascular access device, the nurse meets resistance. The nurse
would:
1. Check the clamp on the catheter.
2. Manipulate the catheter.
3. Apply force to the syringe.
4. Discontinue the site.
Answer: Check the clamp on the catheter.
Rationale:
The nurse would check the clamp on the catheter because the catheter is clamped when not in
use; unclamping the catheter is necessary to initiate flushing of the catheter. Applying force to
the syringe could result in damage to the catheter. Manipulating the catheter could result in
misplacement of the catheter in the vena cava. Discontinuing the site would require a
physician’s order.
10. The nurse has successfully completed insertion of a peripheral venous catheter.
Documentation following the procedure includes:
Select all that apply.
1. Size, length, and type of catheter.
2. Client complaints of pain during the procedure.
3. Method of securing the catheter.
4. Complications of the procedure.
5. Client participation with the procedure.
Answer: 1. Size, length, and type of catheter.
2. Client complaints of pain during the procedure.
3. Method of securing the catheter.
4. Complications of the procedure.
Rationale:
Size, length, and type of catheter. Documentation of the size, length, and type of catheter will
objectively describe the care rendered during the procedure. This also allows for tracking
client outcomes and monitoring care. Client complaints of pain during the procedure.
Documentation of client complaints of pain during the procedure will objectively describe the
care rendered during the procedure and the client’s response to the procedure. This also
allows for tracking client outcomes and monitoring care. Method of securing the catheter.
Documentation of the method of securing the catheter will objectively describe the care
rendered during the procedure. This also allows for tracking client outcomes and monitoring
care. Complications of the procedure. Accurate documentation of complications will
objectively describe the care rendered during the procedure. This also allows for tracking
client outcomes and monitoring care. Client participation with the procedure. Client
participation with the procedure is not considered pertinent information that should be
documented when an infusion-therapy-related procedure has been performed.
11. The nurse understands that the purpose of accurate documentation of the care of
intravenous access devices is to:
Select all that apply.
1. Describe the care rendered.
2. Describe the client’s response.
3. Allow for tracking outcomes.
4. Prevent injury to the client.
5. Inform the physician of the procedure.
Answer: 1. Describe the care rendered.
2. Describe the client’s response.
3. Allow for tracking outcomes.
Rationale:
Describe the care rendered. Describing the care rendered will objectively reflect the purpose
of accurate documentation. Describe the client’s response. Describing the client’s response
will objectively reflect the purpose of accurate documentation. Allow for tracking outcomes.
Allowing for tracking of outcomes will objectively reflect the purpose of accurate
documentation. Prevent injury to the client. Preventing injury to the client is incorrect
because this is not the purpose of documentation and does not influence safety of the client.
Inform the health care provider of the procedure. Informing the health care provider of the
procedure is incorrect because the purpose of accurate documentation is to track the care in
the client’s medical record.
12. The nurse inspects the intravenous catheter after removal. Documentation would include:
Select all that apply.
1. Size of catheter.
2. Length of catheter.
3. Type of catheter.
4. Condition of catheter.
5. Condition of access caps.
Answer: 1. Size of catheter.
2. Length of catheter.
3. Type of catheter.
4. Condition of catheter.
Rationale:
Size of catheter. Documentation of the size of the catheter is necessary after discontinuation
of an intravenous catheter to verify that the catheter did not get sheared or broken when
entering the client’s vascular system. Length of catheter. Documentation of the length of the
catheter is necessary after discontinuation of an intravenous to verify that the catheter did not
get sheared or broken when entering the client’s vascular system. Type of catheter.
Documentation of the type of catheter is necessary after discontinuation of an intravenous
catheter. Condition of catheter. Documentation of the condition of the catheter is necessary
after discontinuation of an intravenous catheter because this data will verify the intactness of
the catheter and verify that the catheter did not get sheared or broken when entering the
client’s vascular system. Condition of access caps. This portion of intravenous catheter
insertion does not enter the client’s vascular system.
13. A client complains of heaviness and swelling in the extremity of the intravenous infusion.
The nurse would first:
1. Discontinue the catheter.
2. Flush the catheter.
3. Document the finding.
4. Notify the physician.
Answer: Discontinue the catheter.
Rationale:
The nurse should discontinue the catheter when any sign of phlebitis occurs. Flushing the
catheter will cause further irritation of the surrounding tissue. Documenting the finding is
necessary; however, it is not the initial intervention that should be implemented. Notifying
the health care provider is necessary to obtain treatment of the infiltration, but this is not the
initial intervention that would be performed.
14. Which of the following nursing diagnoses would the nurse include in the plan of care for
a client with a catheter embolism?
1. Alteration in Comfort
2. Impaired Skin Integrity
3. Fluid-Volume Deficit
4. Ineffective Coping
Answer: Alteration in Comfort
Rationale:
Alteration in Comfort is the correct diagnosis because the client will often experience chest
pain with catheter embolism. Impaired Skin Integrity is incorrect because the catheter has
broken inside the client’s vasculature and skin integrity will not be altered. Catheter
embolism does not reflect signs of fluid loss; it will reflect signs of decreased vascular
perfusion. Ineffective Coping is incorrect because the manner in which a client copes does
not impact this life-threatening emergency.
15. Following insertion of a peripheral vascular device, the client complains of shortness of
breath, chest pain, and palpitations. The nurse would initially:
1. Place a tourniquet proximal to the site.
2. Notify the physician.
3. Obtain vital signs.
4. Obtain radiographic studies.
Answer: Place a tourniquet proximal to the site.
Rationale:
If a catheter embolism is suspected, immediate interventions need to be initiated; the nurse
would secure a tourniquet on the client’s arm to minimize movement of the catheter. Vital
signs would need to be obtained after the tourniquet is placed. The physician would need to
be notified, but this is not the initial intervention Radiographic studies may be indicated to
determine the location of the catheter, but this will be implemented after placement of the
tourniquet, notification of the health care provider, and vital signs are obtained.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
