ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 13 : Intravenous Therapy Questions
Question 1 of 5
A central venous catheter has been inserted in the right subclavian vein of the client. Which of the following would be the priority nursing action before total parenteral nutrition (TPN) can be started?
Correct Answer: A
Rationale: Insertion of a central venous access device in the subclavian can result in an accidental puncture of the pleural membrane, resulting in a pneumothorax. Verification of the insertion site is completed before TPN is started. Swelling, redness, and drainage are symptoms of infection which would not be present immediately following insertion. Hyperglycemia is a common occurrence with the use of hypertonic solutions such as those found in TPN, but because the TPN has not been started, this is not a priority assessment. Cold solutions can result in venous spasms but letting the solution warm is not the priority.
Question 2 of 5
The nurse is caring for a client who has an order to receive Hespan IV. The client asks the nurse what this solution is for. What would be a suitable response(s) from the nurse? Select all that apply.
Correct Answer: A,B,C,E
Rationale: Plasma expanders are nonblood solutions, such as dextran 40 (Rheomacrodex) and hetastarch (Hespan), that pull fluid into the vascular space. Hespan is not artificial blood. Hespan is a colloid solution which can be used instead of a blood transfusion to replace blood, and can be used to treat hypovolemic shock.
Question 3 of 5
In providing nursing care to a client, which action(s) should the nurse take to reduce the risk of administering a contaminated intravenous (IV) solution? Select all that apply.
Correct Answer: C,D,E
Rationale: Inspecting the solution to make sure the solution is clear, transparent, and does not contain a precipitant is the primary action to be taken prior to any IV administration. In-line filters are not used routinely on peripheral IVs but are used for TPN and blood transfusions. IV drugs are often packaged in the powder form. The nurse should inspect the IV container for expiration date and should not use those solutions that are past the expiration date or leaking.
Question 4 of 5
The RN is training other RNs at the hospital to insert midline catheters. What would the RN teach the other RNs about how many inches of the catheter should be inserted into the required site?
Correct Answer: B
Rationale: A midline catheter is 7 to 8 inches long, but only 3 to 6 inches of the catheter are inserted. A midline catheter should not be inserted 1 to 2 inches, 7 to 8 inches, or 8 to 9 inches.
Question 5 of 5
The client is going out on pass for the afternoon with family. The health care provider has prescribed that the client's venipuncture device needs to be temporarily capped. How will the nurse ensure that the vein remains patent?
Correct Answer: B
Rationale: When a venipuncture device is temporarily capped, the vein is kept patent by flushing the lock with saline or heparinized saline. TPN solutions are used to provide nutrition, and colloid solutions such as albumin and cryoprecipitate are used to replace circulating blood volume; these solutions are not used to flush locks.