Nursing: Administering IV Fluids and Managing Fluid Overload

110 Questions

What is a common cause of infiltration during IV therapy?

Improper placement of the IV catheter

What is the first step in managing infiltration during IV therapy?

Stop the infusion and remove the device

Why are IV flow-control devices recommended for older and pediatric patients?

To prevent fluid overload

What is a sign of fluid overload that a nurse should monitor for?

Increased heart rate

What should be documented when administering IV fluids?

The total amount of fluid administered and any adverse responses

What is a symptom of infiltration?

Burning sensation

Why is it important to regularly assess the patient for signs of fluid overload?

To prevent fluid overload complications

What should be done to increase patient comfort when managing infiltration?

Elevate the limb

What is the primary cause of phlebitis in the context of peripheral IV therapy?

Administration of acidic or alkaline solutions

What is the first step in managing phlebitis during IV therapy?

Stop the infusion at the first sign of redness or pain

What is a sign of infection at the IV site?

Elevated temperature

What should be done to the IV site if infection is suspected?

Stop the infusion and notify the prescriber

What is a common consequence of vein trauma during IV catheter insertion?

Phlebitis

Why is it essential to use an appropriate IV catheter size for the vein?

To prevent vein trauma

What is a sign of phlebitis at the IV site?

Redness or tenderness at the site of the tip of the catheter

What should be done to document a patient's condition and interventions in the context of IV therapy?

Document the patient's condition and interventions

If the IV is inserted into the antecubital area, what can affect the flow of the solution?

Bending the arm at the elbow

What is a consideration when regulating the rate of the infusion?

The age of the client

What is a sign of infiltration?

Swelling or puffiness at the insertion site

What should be done if infiltration occurs?

Stop the infusion and remove the catheter

What is a sign of phlebitis?

Pain and tenderness in the area

What should be done if phlebitis occurs?

Stop the infusion and restart at another site

How often should the IV flow rate be monitored?

Every hour

What is a nursing consideration for IV therapy?

Assess for fluid overload

What is the primary function of a roller clamp?

To regulate the speed or stop an infusion by gravity

What is the main difference between macro-drip and micro-drip IV tubing?

The number of drops per milliliter delivered

Where is the drop factor typically located?

On the packaging of the IV tubing

What is the primary use of macro-drip IV tubing?

In adult care for routine primary infusions

What is the purpose of verifying the drop factor?

To calculate medication administration rates

What is unique about micro-drip IV tubing?

It is used for pediatric or neonatal care

What is the relationship between a primary IV administration set and the drop factor?

The drop factor is used to calculate the flow rate of the primary IV set

What is the main characteristic of a micro-drip infusion set?

It delivers 60 drops per milliliter

What is the primary factor that determines the drop factor of a macrodrip set?

The number of drops per mL of fluid

What is the formula to calculate the gravity flow rate in IV administration?

mL/hr divided by 60 minutes x drop factor

What is the effect of increasing the height of the IV bag on the infusion rate?

It increases the infusion rate

What is the purpose of regulating IV flow rates?

To ensure the correct amount of fluid is administered

What is the drop factor of a microdrip set?

60 drops per mL

What is the effect of a larger catheter bore on the infusion rate?

It increases the infusion rate

How often should the IV flow rate be monitored?

It depends on the patient's condition

What is the purpose of using an appropriate IV catheter size for the vein?

To prevent vein trauma

What is the primary reason for regularly assessing the patient for signs of fluid overload during IV therapy?

To prevent complications in older and pediatric patients

What is the primary benefit of using IV flow-control devices for older and pediatric patients?

To minimize the risk of fluid overload complications

What is the most common cause of infiltration during IV therapy?

All of the above

What is the primary goal of managing infiltration during IV therapy?

To increase patient comfort and reduce symptoms

What should be done to the affected limb when managing infiltration during IV therapy?

Apply a warm compress to increase comfort

What is the primary importance of documenting IV administration?

To ensure accountability and accuracy in IV administration

What is the primary risk associated with fluid overload during IV therapy?

Cardiovascular complications

What is the primary benefit of using IV flow-control devices in IV therapy?

To ensure accurate flow rate regulation

What should be done if large bubbles are present in the IV line?

Keep running the fluid through the line until they are gone

What is the primary benefit of using programmable infusion pumps?

They deliver the fluid at an accurate rate and have built-in safety features

What information is displayed on the infusion pump screen under 'VTBI'?

The volume of fluid left in the bag

What is the purpose of identifying the drop factor of an IV administration set?

To determine the flow rate of the infusion

What should be done to the 'total volume infused' display on the infusion pump at the end of the shift?

Reset to zero and start counting for the next shift

What is the unit of measurement for programming the infusion pump rate?

mL/hour

Why is it important to remove large bubbles from the IV line?

To prevent air embolism and other complications

What is the purpose of the 'rate' display on the infusion pump screen?

To display the flow rate of the infusion

What is the primary function of a hypertonic solution in medical treatment?

To pull fluid from the cells

Which of the following IV tubing sets is designed for precise administration in small amounts, especially for neonates or pediatric patients?

Micro (Primary) IV tubing set

What is the flow rate of a Macro (Primary) IV tubing set?

10 to 20 gtt/mL

Why is it important to measure intake and output in patients receiving Intravenous Therapy?

To monitor for both electrolyte imbalances and fluid overload

What is the purpose of a Buretrol IV tubing set?

To replace the 'Select-a-flow' administration device

What is a characteristic of a hypotonic solution?

A low concentration of solute

What is the effect of a hypotonic solution on a cell?

The cell swells

What is a potential complication of IV therapy in patients with a history of heart failure or hypertension?

All of the above

Match the following components of IV tubing with their descriptions:

Drip Chamber = Part of the tubing where you can watch the fluid dripping Roller Clamp = Used to regulate the flow of IV fluid Spiked End = Attaches to the IV bag Pinch Clamp = Alternative to roller clamp in some tubing

Match the following IV tubing types with their characteristics:

Macro-Drip Tubing = Has a larger drop factor than micro-drip tubing Micro-Drip Tubing = Used for pediatric or neonatal care Secondary IV Administration Set = Used for adding medication to primary IV line Primary IV Administration Set = Connected directly to the IV bag

Match the following steps in IV tubing preparation with their descriptions:

Removing the Cap = Expose the spike that goes into the IV bag Priming the Tubing = Removing air from the line by squeezing the drip chamber Opening the Roller Clamp = Allowing fluid to flow through the tubing Attaching the Tubing to the IV Access = Connecting the sterile end of the tubing to the patient

Match the following components of IV flow regulation with their functions:

Roller Clamp = Regulates the flow of IV fluid Drop Factor = Determines the number of drops per mL of fluid IV Flow-Control Devices = Used for older and pediatric patients to regulate flow rates Gravity = Affects the infusion rate by increasing the height of the IV bag

Match the following IV administration sets with their characteristics:

Primary IV Administration Set = Connected directly to the IV bag Secondary IV Administration Set = Used for adding medication to primary IV line Macro-Drip IV Tubing = Has a larger drop factor than micro-drip tubing Micro-Drip IV Tubing = Used for pediatric or neonatal care

Match the following IV tubing preparation steps with their importance:

Removing the Cap = Prevents contamination of the spike Priming the Tubing = Prevents air embolism Opening the Roller Clamp = Allows fluid to flow through the tubing Attaching the Tubing to the IV Access = Maintains sterility of the IV access

Match the following IV flow regulation methods with their purposes:

Gravity = Increases the infusion rate by increasing the height of the IV bag Roller Clamp = Regulates the flow of IV fluid IV Flow-Control Devices = Used for older and pediatric patients to regulate flow rates Drop Factor = Determines the number of drops per mL of fluid

Match the following IV tubing components with their uses:

Drip Chamber = Part of the tubing where you can watch the fluid dripping Spiked End = Attaches to the IV bag Roller Clamp = Used to regulate the flow of IV fluid Pinch Clamp = Alternative to roller clamp in some tubing

Match the type of IV tubing with its drop factor:

Macro-drip = 10, 15, or 20 drops per milliliter Micro-drip = 60 drops per milliliter Primary IV = 15 drops per milliliter Secondary IV = 20 drops per milliliter

Match the component of a Primary IV administration set with its function:

Sterile spike = Allows air to rise out from a fluid Drip chamber = Prevents fluid or medication from traveling up into the primary IV bag Backcheck valve = Kept ¼ to ½ full of solution Access ports = Used to spike the IV fluid bag

Match the type of IV administration with its purpose:

Primary IV = Intermittently administer a secondary medication Secondary IV = Infuse continuous or intermittent fluids or medications Macro-drip = Used for pediatric patients Micro-drip = Used for older patients

Match the IV flow control device with its benefit:

Roller clamp = Used for older and pediatric patients IV flow-control device = Used to regulate the rate of infusion Programmable infusion pump = Used to increase patient comfort Buretrol = Used to prevent fluid overload

Match the IV tubing type with its characteristic:

Macro-drip = Delivers 60 drops per milliliter Micro-drip = Delivers 10, 15, or 20 drops per milliliter Primary IV = Used for antibiotic administration Secondary IV = Used for fluid volume limitation

Match the component of a Primary IV administration set with its purpose:

Drip chamber = Used to calculate the rate of infusion Backcheck valve = Used to administer IV push medications Access ports = Used to infuse secondary medications Sterile spike = Used to prevent fluid or medication from traveling up into the primary IV bag

Match the IV administration set with its purpose:

Primary IV administration set = Used for intermittent administration of secondary medications Secondary IV administration set = Used for continuous or intermittent infusion of fluids or medications Macro-drip infusion set = Used for fluid volume limitation Micro-drip infusion set = Used for antibiotic administration

Match the IV flow control device with its purpose:

Roller clamp = Used to regulate the rate of infusion IV flow-control device = Used to prevent fluid overload Programmable infusion pump = Used to increase patient comfort Buretrol = Used to limit fluid volume

Match the following IV tubing types with their characteristics:

Macro-drip IV tubing = Typically used for adults and delivers a larger volume of fluid per drop Micro-drip IV tubing = Used in pediatric or neonatal care for small amounts of fluids over a long period Primary IV administration set = Used for direct delivery of fluids to the patient Secondary IV administration set = Used for piggybacking medications into the primary IV line

Match the following components with their functions in IV flow regulation:

Roller clamp = Used to regulate the flow of IV fluids Drop factor = Determines the volume of fluid delivered per drop IV pole = Used to hang the IV bag IV bag port = Used to inject medications into the IV bag

Match the following IV administration sets with their characteristics:

Primary IV administration set = Directly delivers fluids to the patient Secondary IV administration set = Used for piggybacking medications into the primary IV line Micro-drip infusion set = Used for small amounts of fluids over a long period Macro-drip infusion set = Typically used for adults and delivers a larger volume of fluid per drop

Match the following IV flow regulation methods with their purposes:

Programmable infusion pumps = Used to accurately regulate the flow rate of IV fluids IV flow-control devices = Used to regulate the flow rate of IV fluids, especially for older and pediatric patients Gravity flow rate = Used to regulate the flow rate of IV fluids based on the height of the IV bag Roller clamp = Used to manually regulate the flow of IV fluids

Match the following IV tubing components with their purposes:

IV tubing port = Used to inject medications into the IV bag Cap of the IV tubing port = Used to protect the port from contamination Roller clamp = Used to regulate the flow of IV fluids IV bag = Used to store the IV fluid

Match the following IV flow regulation considerations with their purposes:

Drop factor = Determines the volume of fluid delivered per drop Catheter bore size = Affects the flow rate of IV fluids IV bag height = Affects the flow rate of IV fluids IV flow rate = Affects the delivery of IV fluids to the patient

Match the following IV administration sets with their purposes:

Match the following IV flow regulation methods with their benefits:

Programmable infusion pumps = Provides accurate regulation of the flow rate of IV fluids IV flow-control devices = Provides improved regulation of the flow rate of IV fluids, especially for older and pediatric patients Gravity flow rate = Provides a cost-effective method of regulating the flow rate of IV fluids Roller clamp = Provides a simple method of regulating the flow of IV fluids

A primary IV administration set can only be used for continuous fluid infusion.

False

The drip chamber of a primary IV administration set is used to calculate the flow rate of the fluid in drops per minute.

True

A macro-drip infusion set delivers 10, 15, or 20 drops per milliliter of fluid.

False

The backcheck valve in a primary IV administration set prevents air from entering the IV fluid bag.

False

Access ports in a primary IV administration set are used to infuse secondary medications and administer IV push medications.

True

A secondary IV, also known as an 'IV piggyback', is used to continuously infuse fluids or medications.

False

A primary IV administration set consists of a sterile spike, drip chamber, and backcheck valve only.

False

The Buretrol is used as a fluid volume limiter in IV therapy.

True

IV tubing with a flow rate of 10 to 20 gtt/mL is designed for precise administration of small amounts.

False

The drop factor of a microdrip set is 10 gtt/mL.

False

A Buretrol can be used in place of a macro (primary) IV administration set.

False

IV flow-control devices are recommended for older and pediatric patients to prevent fluid overload.

False

A primary IV administration set has a flow rate of 60 gtt/mL.

False

The primary function of a roller clamp is to regulate the IV flow rate.

True

Macro-drip IV tubing is used for precise administration of small amounts.

False

The drop factor of a macrodrip set determines the infusion rate.

True

Micro-drip infusion sets deliver 10, 15, or 20 drops per milliliter.

False

The primary function of a roller clamp is to regulate the flow of medication administration rates.

False

Drop factors are only used for pediatric or neonatal care.

False

Macro-drip sets are used for routine primary infusions for pediatric patients.

False

The drop factor is located on the packaging of the IV bag.

False

Primary IV administration sets are only used for continuous infusions.

False

Study Notes

Complications of Intravenous Therapy

Fluid overload can be identified by increased heart rate, increased respirations, and increased lung congestion.
Older and pediatric patients are at risk for complications of fluid overload, and IV flow-control devices should be used when administering IV fluids to these age groups.

Infiltration

Infiltration occurs when IV fluid or medications leak into the surrounding tissue.
Causes of infiltration include improper placement or dislodgment of the catheter, and patient movement.
Signs and symptoms of infiltration include swelling, discomfort, burning, and/or tightness, cool skin and blanching, and decreased or stopped flow rate.
Management of infiltration involves stopping the infusion and removing the device, elevating the limb to increase patient comfort, applying a warm compress, checking the patient's pulse and capillary refill time, and documenting findings and interventions.

IV Flow Rate

A slower rate is usually necessary for older adults or those who are at risk of fluid overload (e.g., heart disease or client with head injury).
A faster IV flow rate is therapeutic for patients who have lost large amounts of body fluids and those who are severely dehydrated.
Never increase the rate of infusion if it is running behind schedule; instead, check for obstructions and collaborate with primary care providers to determine the patient's ability to tolerate an increased flow rate.

Nursing Considerations

Monitor for infiltration or irritation by inspecting the insertion site for fluid infiltration.
Look for signs of infiltration, including swelling or puffiness, coolness, pain at the insertion site, and tenderness in the area.
Monitor for signs of phlebitis, including pain and tenderness, swelling, and warmth in the area.
Regularly monitor IV flow rate, even if the solution is administered through an IV pump.

Phlebitis

Phlebitis is the inflammation of the vein, often associated with acidic or alkaline solutions or solutions with high osmolarity.
Signs and symptoms of phlebitis include redness or tenderness at the site of the tip of the catheter or along the path of the vein, and a puffy area over the vein and warmth around the insertion site.
Management of phlebitis involves stopping the infusion at the first sign of redness or pain, applying warm, moist compresses to the area, and documenting the patient's condition and interventions.

Infection of IV Site

Local or systemic infection is a potential complication of IV therapy, characterized by redness and discharge at the IV site and elevated temperature.
Management of infection involves stopping the infusion, notifying the prescriber, removing the device, and culturing the site and catheter as ordered, and monitoring the patient's vital signs.

Documentation

Proper documentation is essential, including documenting all findings, including the total amount of fluid administered, and any adverse responses of the client.

IV Tubing & Administration Sets

IV tubing is also referred to as "Y ports"
Roller clamp is used to regulate the speed or stop an infusion by gravity
Drop factor is located on the packaging of the IV tubing and is important to verify when calculating medication administration rates
Macro-drip sets are used for routine primary infusions for adults and deliver 10, 15, or 20 drops per milliliter
Micro-drip IV tubing is used in pediatric or neonatal care where small amounts of fluids are administered over a long period of time and delivers 60 drops per milliliter

Calculation of IV Infusion Rates

Formula to calculate gravity flow rates: mL/hr divided by 60 minutes (1 hour) x drop factor = drops/minute (rounded off)
Examples of calculating gravity flow rates using macro-drip drop factors:
- 125mL/hr using tubing with a drop factor of 10: 125mL/hr divided by 60 minutes = 2.08mL/min, 2.08mL/min x 10 drop factor = 21 drops/min
- 125mL/hr using tubing with a drop factor of 15: 125mL/hr divided by 60 minutes = 2.08mL/min, 2.08mL/min x 15 drop factor = 31 drops/min
- 125mL/hr using tubing with a drop factor of 20: 125mL/hr divided by 60 minutes = 2.08mL/min, 2.08mL/min x 20 drop factor = 42 drops/min

Regulatory Factors Affecting IV Infusion Rates

Size of the catheter: a larger bore allows solution to flow faster
Height of the IV bag: the higher the IV bag, the faster the infusion will flow
Position of the insertion site: a change in the position of the client's arm may decrease the flow, while elevation on a pillow may increase flow rate

IV Infusion Pumps

IV infusion pumps deliver the fluid at an accurate rate and have built-in safety features, such as detection of air in the lines
Pumps reduce the risk of fluid running in too fast and assist in detecting infiltration or occlusions
Pumps are set at a rate of mL/hr, which is stated in the physician's order

Complications of IV Therapy

Infiltration: occurs when IV fluid or medications leak into the surrounding tissue, causing swelling, discomfort, burning, and/or tightness, cool skin and blanching, and decreased or stopped flow rate
Management of infiltration: stop the infusion and remove the device, elevate the limb to increase patient comfort, apply a warm compress, check the patient's pulse and capillary refill time, and document findings and interventions
Hypertonic solutions: contain a high concentration of solute in their solution compared to another solution, causing cells to shrivel; used to pull fluid from the cells
Hypotonic solutions: contain a low concentration of solute in their solution compared to another solution, causing cells to swell; used to promote fluid to flow into cells and expand the intracellular compartment
Possible complications: electrolyte imbalances, edema, fluid overload, especially in patients with a history of heart failure or hypertension

Micro-drip IV Tubing

Used in pediatric or neonatal care for administering small amounts of fluids over a long period of time
Delivers 60 drops per milliliter

Spiking IV Bag

Perform hand hygiene before handling IV bag and tubing
Gather supplies: IV bag and appropriate tubing
Check solution for color and clarity, and inspect bag for leaks
Ensure sterility by checking for signs of contamination, such as discoloration, precipitate, or expiration date

IV Bag and Tubing

IV bag has two ports: one for injecting medications and one for attaching IV tubing
The IV bag port cap pulls off and is used to insert the end of the tubing
Hang the IV bag on the pole and remove the cap without touching the port

IV Tubing

Has a roller clamp that is open, which needs to be pinched closed to prevent fluid flow
Has a drip chamber to allow air to rise out of the fluid and calculate the flow rate
Has a backcheck valve to prevent fluid from flowing back into the IV bag
Has access ports for infusing secondary medications and administering IV push medications

Priming IV Tubing

Remove the plastic cap from the end of the tubing to expose the spike
Insert the spike into the IV bag port without touching the spike to any surfaces
Squeeze the drip chamber to fill it with fluid (1/3 to 1/2 full)
Remove the cap from the other end of the tubing, being careful not to touch it to any surfaces
Open the roller clamp to allow fluid to flow out, watching for air to be removed from the line (priming)
Close the roller clamp once the air is out of the line

IV Tubing & Administration Sets

Primary IV administration sets are used to infuse continuous or intermittent fluids or medications.
Primary IV tubing can be a macro-drip or micro-drip solution set.
Macro-drip infusion sets deliver 10, 15, or 20 drops per milliliter.
Micro-drip infusion sets deliver 60 drops per milliliter.
Primary IV administration sets consist of:
- Sterile spike: must be kept sterile as you spike the IV fluid bag.
- Drip chamber: allows air to rise out from a fluid, used to calculate the rate of fluid administration by gravity (drops per minute).
- Backcheck valve: prevents fluid or medication from traveling up into the primary IV bag.
- Access ports: used to infuse secondary medications and to administer IV push medications.
Secondary IV (IV piggyback): used to intermittently administer a secondary medication, such as an antibiotic, while the primary IV is also running.

Hypertonic Solutions

Hypertonic solutions contain a high concentration of solute in their solution compared to another solution.
When a cell is placed in a hypertonic solution, the water diffuses out of the cell, causing the cell to shrivel.
Examples of hypertonic solutions: D10W and 3% NaCl.
Uses for hypertonic solutions: to pull fluid from the cells.

Hypotonic Solutions

Hypotonic solutions contain a low concentration of solute in their solution compared to another solution.
When a cell is placed in a hypotonic solution, the water diffuses into the cell, causing the cell to swell.
Examples of hypotonic solutions: 0.45% sodium chloride solution and 0.33% NaCl.
Uses for hypotonic solutions: to promote fluid to flow into cells, to expand the intracellular compartment, such as cellular dehydration.

Possible Complications

Patients on an IV are closely monitored for complications, such as:
- Electrolyte imbalances
- Edema
- Fluid overload, especially in patients with a history of heart failure or hypertension
Importance of measuring intake and output on all patients receiving Intravenous Therapy.

IV Tubing Types

Macro (Primary): with a flow rate of 10 to 20 gtt/mL, used for rapid infusion of large volumes.
Micro (Primary): delivering 60 gtt/mL, designed for precise administration in small amounts, especially for neonates or pediatric patients.
Buretrol: may be used in lieu of the "Select-a-flow" administration device, also referred to as “Y ports.”

Roller Clamp and Drop Factors

Roller clamp: used to regulate the speed, or stop, an infusion by gravity.
Drop factor: located on the packaging of the IV tubing, important to verify when calculating medication administration rates.
Macro-drip sets are used for routine primary infusions for adults.
Micro-drip IV tubing is used in pediatric or neonatal care where small amounts of fluids are administered over a long period of time.

Assess patients for signs of fluid overload, use IV flow-control devices for older and pediatric patients, and properly document findings. Learn how to manage fluid overload risks and complications.

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