IV Therapy: Local Complications

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Which of the following is the MOST appropriate initial action to take when encountering an IV infiltration?

Administer an antihistamine to reduce local inflammation.
Discontinue the IV infusion and assess the site. (correct)
Apply a tourniquet proximal to the IV site to limit further fluid leakage.
Immediately flush the IV line with normal saline to clear the obstruction.

Why are transparent dressings like Tegaderm recommended for IV sites?

They reduce the risk of catheter-related bloodstream infections by creating a sterile barrier.
They contain antimicrobial agents that proactively prevent local infections.
They actively absorb any leaking fluid, keeping the site dry and preventing skin maceration.
They allow for easy visualization of the IV insertion site without removing the dressing. (correct)

A patient with an IV reports a burning sensation at the insertion site. What is the priority nursing intervention?

Slow the infusion rate to reduce irritation.
Document the complaint and reassess in one hour.
Apply a cold compress to numb the area.
Assess the IV site for signs of complications such as phlebitis or infiltration. (correct)

Which factor contributes to phlebitis?

Prolonged IV placement (C) Signup and view all the answers

When discontinuing an IV, which finding in documentation BEST indicates there was IV infiltration present?

Edema and pallor noted proximal to the IV site. (C) Signup and view all the answers

When should a nurse suspect an IV infiltration rather than phlebitis?

The skin around the IV site is cool to the touch and swollen. (D) Signup and view all the answers

If an IV site exhibits signs of infiltration and there is a prescription to continue IV fluids, where should the new IV be ideally started?

Proximal to the infiltrated site on the same arm. (D) Signup and view all the answers

Why is it important to check capillary refill and distal pulses when addressing an IV infiltration?

To evaluate circulatory impairment from the infiltration. (A) Signup and view all the answers

A patient receiving intravenous fluids suddenly develops chest pain, dyspnea, and cyanosis. Upon auscultation, wheezes are noted. Which complication is MOST likely occurring?

Venous air embolism (B) Signup and view all the answers

Which action is MOST important when a nurse suspects a venous air embolism in a central line?

Positioning the patient on their left side with the head lower than the heart (C) Signup and view all the answers

A patient receiving a rapid IV infusion of an antibiotic reports a flushed feeling, headache, and chills. The patient's blood pressure is elevated. Which complication is MOST likely?

Speed shock (B) Signup and view all the answers

A nurse is caring for a patient receiving IV fluids. What is the MOST effective strategy to prevent venous air embolism related to IV administration?

Ensuring all IV connections are tightly secured and using an infusion pump (A) Signup and view all the answers

During insertion of a peripheral IV, a patient winces and reports sudden, sharp pain at the IV site. After the removal of the catheter, the nurse notes that a portion of it is missing. What is the priority nursing intervention?

Applying a tourniquet above the insertion site (B) Signup and view all the answers

Which assessment finding is MOST indicative of a catheter embolism?

Sudden, sharp pain at the IV site with minimal blood return and a shortened catheter (C) Signup and view all the answers

A patient is receiving intravenous fluids via a central line. The nurse observes the solution container is almost empty. What is the MOST appropriate action?

Replace the solution container before it empties completely. (B) Signup and view all the answers

What is the priority nursing intervention when responding to speed shock?

Immediately discontinuing the infusion and notifying the provider (C) Signup and view all the answers

What is the primary intervention when noticing signs and symptoms of thrombophlebitis in a patient receiving intravenous therapy?

Discontinue the IV and restart it at a different site. (D) Signup and view all the answers

Which action is most important to prevent hematoma formation during intravenous catheter insertion?

Maintain pressure on the venipuncture site after cannula removal. (A) Signup and view all the answers

A patient receiving vancomycin intravenously reports pain, tightness, and blanching at the insertion site. What immediate action should the nurse take?

Stop the infusion, disconnect the administration set, and aspirate fluid from the catheter. (C) Signup and view all the answers

What nursing intervention is most effective in preventing local infections related to IV therapy?

Practicing thorough hand hygiene and using sterile technique during IV insertion. (D) Signup and view all the answers

What should the nurse do first when a patient reports a sharp pain at the IV site that travels up the arm, possibly indicating venous spasm?

Apply a warm compress to the IV site. (A) Signup and view all the answers

Which of the following is the most effective strategy for preventing septicemia related to IV therapy?

Maintaining strict aseptic technique during insertion and site care. (B) Signup and view all the answers

A patient with a history of heart failure is receiving IV fluids at 125 mL/hr. Which assessment finding is most indicative of fluid overload?

Crackles in the lungs and jugular vein distension. (C) Signup and view all the answers

What strategy is most important for preventing fluid overload in elderly patients receiving IV therapy?

Monitoring intake and output closely and maintaining the prescribed flow rate. (C) Signup and view all the answers

Which of the following is a late sign/symptom of septicemia that requires immediate intervention?

Hypotension and altered mental status. (B) Signup and view all the answers

Which of the following is a common cause of venous spasm during IV infusions?

Administration of cold IV solutions. (B) Signup and view all the answers

What is the rationale for using warm compresses in the treatment of thrombophlebitis?

To promote vasodilation, reduce pain, and promote circulation. (C) Signup and view all the answers

What is the MOST important factor in preventing fluid overload in a patient receiving IV fluids?

Monitoring intake and output accurately. (C) Signup and view all the answers

Which of the following is a sign of extravasation that differs it from infiltration?

It occurs only with vesicant solutions (D) Signup and view all the answers

When should IV solutions be changed to prevent local infection?

Every 24 hours (A) Signup and view all the answers

Which IV complication is characterized by redness and swelling at the IV site along with purulent discharge?

Local Infection (D) Signup and view all the answers

Infiltration

Inadvertent administration of non-vesicant solution into surrounding tissue.

Non-vesicant solutions

Non-irritating to veins and tissues