Infusion Therapy

A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?

• Redness at the catheter insertion site

• Report of headache and stiff neck

• Temperature of 100.1° F (37.8° C)

• Pain rating of 8 on a scale of 0-10

A nurse assesses a client’s peripheral IV site, and notices edema and tenderness above the site. What action will the nurse take next?

• Apply cold compresses to the IV site.

• Elevate the extremity on a pillow.

• Flush the catheter with normal saline.

• Stop the infusion of intravenous fluids.

While assessing a client’s peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 1.5 inch (4-cm) venous cord. How will the nurse document this finding?

• “Grade 3 phlebitis at IV site”

• “Infection at IV site”

• “Thrombosed area at IV site”

• “Thrombosed area at IV site”

ID: 22244801057

A nurse prepares to insert a peripheral venous catheter in an older adult. What action could the nurse take to protect the client’s skin during this procedure?

• Lower the extremity below the level of the heart.

• Apply warm compresses to the extremity.

• Tap the skin lightly and avoid slapping.

• Place a washcloth between the skin and tourniquet.

A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure?

• Notifies the pharmacy of the IV potassium order.

• Assesses the client’s IV site every hour during infusion.

• Sets the IV pump to deliver 30 mEq of potassium an hour.

• Double-checks the IV bag against the order with the precepting nurse.

A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which primary health care provider order does the nurse implement first?

• Encourage oral fluid intake.

• Connect the client to a cardiac monitor.

• Assess urinary output.

• Administer oral calcitonin.

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital?

• Ask family members to speak quietly to keep the client calm.

• Assess urine color, amount, and specific gravity each day.

• Encourage the client to drink at least 1 L of fluids each shift.

• Dangle the client on the bedside before ambulating.

A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms are NOT priority findings for this condition?

• Increased pulse rate

• Distended neck veins

• Decreased blood pressure

• Visual disturbances