Uploaded by Joseph Miller

IV Therapy

advertisement
IV Therapy
-
For clients who require fluids, electrolytes, medications, or nutritional supplements that
cannot be administered orally, or that must be given on a continuous basis.
IV fluids are infused to maintain fluid balance, replace fluid losses, and treat electtolyte
imbalances.
Isotonic-
Preparing IV Tubing
-
-
Perform hand hygiene
Confirm client’s prescription for IV access
Gather all necessary supplies
For continuous infusion- primary tubing, extension tubing, the IV solution, the time tape,
the tubing label, compare the solution to the medication on the MAR.
Verify the solution and the medication on the mar match the right client, medication
route, dose, time. Also verify the right IV solution and duration or volume to infuse are
on the record.
Remove IV solution from its packaging and gently apply pressure to the bag remove and
inspect bag for tears or leaks. Check the color, clarity, and expiration date of the solution
Next remove the primary IV tubing and extension tubing from its packaging. Remove the
protective caps and connect the tubing. Move the roller clamps so it is about 1-2 inches
approximately 2-5 cm below the drip chamber, and then place the roller clamp in the off
position. Compare the IV solution with the MAR for the 2nd time. Is it the right solution,
the right volume, the right route. Remove the protective cover from the tubing port on the
bag solution. Remove the protective cap from the tubing insertion spike and insert the
spike into the tubing part of the bag. Be careful not to contaminate the spike. If the
solution is in a glass bottle, clean the black rubber stopper with alcohol before inserting
the spike. If the spike becomes contaminated, discard the tubing and use a new infusion
set. Once you insert the spike into the bag of fluid, hang the bag on the IV pole and
squeeze the drip chamber 2 or 3 times to allow it to fill one third to half full. Loosen the
cap from the end of the tubing, Hold over the sink and slowly roll the roller clamp to
allow fluid the fill or prime the tubing. If using multiple port tubing, turn the port upside
down and tap gently to them with fluid and to remove any air. Once you prime the
tubing, check the entire length of the tubing to make sure there are no air bubbles in it. If
you see air bubbles, tap the tubing gently to remove them. Replace or tighten the cap at
the end of the tubing. Place the time tape on the bag of solution and the tubing label on
the tubing near the drip chamber. Add passive disinfection caps to all ports of the IV
tubing. Gather and dispose of all waste in the appropriate receptacle. Perform hand
hygiene.
1. A nurse is initiating a peripheral IV infusion punctures the skin and selected vein and
observes blood return in the flashback chamber of the IV catheter. Which of the
following actions should the nurse perform next? Lower the catheter until it is almost
flush with the skin and advance the catheter into the vein with the finger hub. Once blood
return is observed in the flashback chamber, the over-the-needle catheter should be advanced into the
vein using the finger hub.
2. Which of the following is an important nursing action when converting an IV infusion to a
saline lock? Flush the IV catheter to confirm patency. It is essential to attach the primed saline
lock adapter to the extension tubing and to flush the tubing with normal saline to confirm patency.
3. A nurse is discontinuing an IV infusion. For which of the following reasons is it important
to verity and document the integrity and condition of the IV catheter? A broken-off
catheter tip indicates the risk for an embolus
4. A nurse has just initiated a new peripheral IV infusion of 5% dextrose in water for
continuous infusion. How often should the nurse plan to replace the primary infusion
tubing? Every 96 hours (The Centers for Disease Control and Prevention and the Infusion
Nurses' Society recommend changing the IV tubing no more than every 92 hours unless
the tubing has been contaminated, punctured, or obstructed.
5. A nurse is discontinuing a peripheral IV catheter. Upon removal, the nurse should assess
the catheter for which of the following? An intact catheter tip. The tip of the catheter can
break off, thus creating an embolus. To limit the movement of the embolus, the nurse should apply a
tourniquet high on the extremity where the IV line was located and notify the provider immediately.
6. A nurse is removing an IV catheter from a patient whose IV infusion has been
discontinued. Which of the following actions is appropriate? Pull the catheter straight
back from the insertion site. With the catheter stabilized and using a slow, steady movement, the
nurse should withdraw the catheter straight back and away from the insertion site, making sure to keep
the hub parallel to the skin.
7. A nurse is caring for a client who is in early stage of renal failure and as a prescription for
the infusion of IV fluids. Which of the following IV Fluids does the nurse anticipate a
prescription for and why? 0.45 % sodium chloride because it dilutes extracellular fluid and
rehydrates the cells. Infusing a hypotonic solution, such as 0.45% sodium chloride, moves fluid into
the cells, thus enlarging and rehydrating them.
8. A nurse has just inserted a peripheral IV Catheter. Which of the following actions should
the nurse take to secure the catheter? Apply an IV securement device. An IV securement
device will help the IV to stay in place and prevent dislodgement.
9. A nurse who has just initiated an TV infusion explains to the patient that complications
are possible and that she will monitor the infusion regularly. The nurse should teach the
patient that which of the following is an indication of early infiltration? Coolness. Coolness
is a classic sign of infiltration, along with swelling, pallor, and possibly tenderness. Infiltration is a
leakage of IV solution out of the intravascular compartment and into the surrounding tissue.
10. A patient is to receive 1,00 mL of 5% dextrose in lactated Ringer's over 8 hours. Using
tubing with a drop factor of 15 gtt/Ml, the nurse should regulate the fluid to infuse at
how many drops per minute? 31 gtt/min
11. A nurse assesses a clients IV’s insertion site and finds that it is red, warm, and slightly
edematous. Which of the following actions should the nurse take? Discontinue the IV line.
The client has classic signs of phlebitis, an inflammation of the vein. The IV line must be discontinued
immediately to reduce the risk of thrombophlebitis and embolism.
Download