Podcast
Questions and Answers
Which of the following is the MOST appropriate gauge size for administering blood transfusions?
Which of the following is the MOST appropriate gauge size for administering blood transfusions?
- 26G (Violet)
- 20G (Pink) (correct)
- 24G (Yellow)
- 22G (Blue)
A patient receiving intravenous fluids exhibits sudden dyspnea, increased blood pressure, and distended neck veins. Which complication should the nurse suspect?
A patient receiving intravenous fluids exhibits sudden dyspnea, increased blood pressure, and distended neck veins. Which complication should the nurse suspect?
- Septicemia
- Phlebitis
- Infiltration
- Fluid volume overload (correct)
What is the rationale behind using an isotonic solution for intravenous fluid replacement?
What is the rationale behind using an isotonic solution for intravenous fluid replacement?
- To maintain fluid balance without causing fluid shifts. (correct)
- To cause fluid to shift out of the cells and into the vascular space.
- To cause fluid to shift into the cells from the vascular space.
- To decrease the amount of fluid circulating in the vascular system.
A nurse assesses a patient's IV site and notes blanching, coolness, and edema around the insertion site. The patient reports pain at the site. What complication is MOST likely occurring?
A nurse assesses a patient's IV site and notes blanching, coolness, and edema around the insertion site. The patient reports pain at the site. What complication is MOST likely occurring?
Which of the following is the MOST important step to take when initiating a blood transfusion?
Which of the following is the MOST important step to take when initiating a blood transfusion?
A patient with thrombocytopenia is prescribed a platelet transfusion. Which of the following is an important consideration for the nurse during administration?
A patient with thrombocytopenia is prescribed a platelet transfusion. Which of the following is an important consideration for the nurse during administration?
A patient receiving a blood transfusion begins to exhibit fever, chills, and anxiety. What is the FIRST action the nurse should take?
A patient receiving a blood transfusion begins to exhibit fever, chills, and anxiety. What is the FIRST action the nurse should take?
Which of the following central venous access devices is inserted into a peripheral vein in the arm?
Which of the following central venous access devices is inserted into a peripheral vein in the arm?
Which of the following is an advantage of using a central venous catheter over a peripheral IV catheter?
Which of the following is an advantage of using a central venous catheter over a peripheral IV catheter?
After inserting a peripheral IV, what should the nurse document?
After inserting a peripheral IV, what should the nurse document?
A proper IV order must include which of the following components?
A proper IV order must include which of the following components?
Which situation requires the use of a large-bore (14-16 gauge) IV catheter?
Which situation requires the use of a large-bore (14-16 gauge) IV catheter?
The PRIMARY reason for using IV therapy to administer medication is to:
The PRIMARY reason for using IV therapy to administer medication is to:
A patient has a peripherally inserted central catheter (PICC) in their right arm. What nursing intervention is MOST important regarding this arm?
A patient has a peripherally inserted central catheter (PICC) in their right arm. What nursing intervention is MOST important regarding this arm?
Which of the following assessments BEST indicates that a hypotonic IV solution is having the desired effect for a patient with intracellular dehydration?
Which of the following assessments BEST indicates that a hypotonic IV solution is having the desired effect for a patient with intracellular dehydration?
What critical information must be included in the two-nurse verification process prior to blood administration?
What critical information must be included in the two-nurse verification process prior to blood administration?
Which assessment finding would indicate a systemic reaction after initiating a blood transfusion?
Which assessment finding would indicate a systemic reaction after initiating a blood transfusion?
A patient is to receive D5 0.45%NS IV at 100 mL/hr. What does 'D5' indicate in this order?
A patient is to receive D5 0.45%NS IV at 100 mL/hr. What does 'D5' indicate in this order?
Which of the following actions is within the scope of practice of a registered nurse (RN) regarding IV therapy?
Which of the following actions is within the scope of practice of a registered nurse (RN) regarding IV therapy?
Routine care of a peripheral intravenous site includes:
Routine care of a peripheral intravenous site includes:
The purpose of Intraosseous (IO) access is to:
The purpose of Intraosseous (IO) access is to:
During the insertion of an IV, the vein rolls away from the catheter. What is the MOST appropriate next step?
During the insertion of an IV, the vein rolls away from the catheter. What is the MOST appropriate next step?
An older adult patient has fragile veins. To minimize trauma during IV insertion, what should the nurse do?
An older adult patient has fragile veins. To minimize trauma during IV insertion, what should the nurse do?
The nurse observes redness, warmth, and palpable cord along the vein during an IV infusion. Which complication is MOST likely?
The nurse observes redness, warmth, and palpable cord along the vein during an IV infusion. Which complication is MOST likely?
A patient is prescribed packed red blood cells (PRBCs) due to anemia. The nurse knows that PRBCs are administered to:
A patient is prescribed packed red blood cells (PRBCs) due to anemia. The nurse knows that PRBCs are administered to:
Which blood type is considered the universal donor?
Which blood type is considered the universal donor?
When administering IV fluids to an elderly patient, which of the following considerations is MOST important to prevent fluid overload:
When administering IV fluids to an elderly patient, which of the following considerations is MOST important to prevent fluid overload:
During a blood transfusion, the nurse observes urticaria and itching. These signs indicate:
During a blood transfusion, the nurse observes urticaria and itching. These signs indicate:
What is the MOST appropriate nursing intervention if an air embolism is suspected in a patient with a central venous catheter?
What is the MOST appropriate nursing intervention if an air embolism is suspected in a patient with a central venous catheter?
Which of the following is a PRIMARY purpose of administering IV fluids for maintenance?
Which of the following is a PRIMARY purpose of administering IV fluids for maintenance?
What is the correct action to take when discontinuing a peripheral IV line?
What is the correct action to take when discontinuing a peripheral IV line?
Which of the following interventions helps prevent infection related to IV therapy?
Which of the following interventions helps prevent infection related to IV therapy?
When selecting a vein for IV insertion, which factor is MOST important to consider:
When selecting a vein for IV insertion, which factor is MOST important to consider:
What is the PRIMARY reason for using a filter during blood product administration?
What is the PRIMARY reason for using a filter during blood product administration?
When administering IV medications via IV push, what important step should the nurse perform?
When administering IV medications via IV push, what important step should the nurse perform?
What is the recommended action if a patient reports pain at the IV insertion site during an infusion?
What is the recommended action if a patient reports pain at the IV insertion site during an infusion?
A hypotonic IV solution will have which effect on red blood cells?
A hypotonic IV solution will have which effect on red blood cells?
Which of the following is a symptom specific to phlebitis?
Which of the following is a symptom specific to phlebitis?
What size of catheter may be used for fragile veins, such as in neonates?
What size of catheter may be used for fragile veins, such as in neonates?
Flashcards
What is IV therapy?
What is IV therapy?
IV therapy delivers fluids, electrolytes, medications, blood products, and nutritional support directly into a patient's vein.
Purposes of IV fluids
Purposes of IV fluids
IV fluids are used for maintenance when oral intake is inadequate and for replacement when losses have occurred.
Types of IV solutions
Types of IV solutions
Crystalloids are solutions containing small molecules (e.g., saline) and colloids contain large molecules (e.g., plasma expanders).
Hypotonic solutions
Hypotonic solutions
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Isotonic solutions
Isotonic solutions
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Hypertonic Solutions
Hypertonic Solutions
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Components of IV Order
Components of IV Order
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Choosing a vein for IV
Choosing a vein for IV
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Peripheral vs Central IV
Peripheral vs Central IV
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IV Catheter Gauge Size
IV Catheter Gauge Size
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PICC Line
PICC Line
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Intraosseous (IO) Access
Intraosseous (IO) Access
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IV Administration Styles
IV Administration Styles
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Routine IV Care
Routine IV Care
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Assess fluid overload
Assess fluid overload
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Infiltration vs. Extravasation
Infiltration vs. Extravasation
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Phlebitis
Phlebitis
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Central Line Complications
Central Line Complications
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Types of Blood Products
Types of Blood Products
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Blood product uses
Blood product uses
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ABO Compatibility
ABO Compatibility
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Blood Transfusion Pre-Checks
Blood Transfusion Pre-Checks
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Two-Nurse Verification
Two-Nurse Verification
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Starting a Transfusion Safely
Starting a Transfusion Safely
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Immediate action to an allergic reaction
Immediate action to an allergic reaction
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Study Notes
- Nursing management of IV therapies covers blood transfusions
- This includes special considerations
- Provision 3 of the ANA Code of Ethics includes promoting, advocating for, and protecting the rights, health, and safety of patients
Why IV Therapy
- Used in all care settings, including hospitals, extended care facilities, outpatient centers, infusion centers, and homes
- Facilitates fluid and electrolyte replacement
- Facilitates medication and blood product administration
- Provides nutritional support
Purposes of IV Fluids
- Maintenance of fluid balance
- Appropriate when oral intake is inadequate
- Needed for fluid replacement when losses have occurred
Solutions Used in Infusion Therapy
- Crystalloid solutions include isotonic, hypotonic, and hypertonic solutions
- Colloid solutions include plasma expanders
Tonicity
- Hypotonic solutions cause fluid to move out of the vascular space into both the intracellular and interstitial spaces
- Isotonic solutions increase the amount of fluid circulating in the vascular system without causing the movement of fluid in or out of cells
- Hypertonic solutions cause fluid to move from the cells into the intravascular space, causing cells to shrink and the extracellular space to expand
Proper IV Order
- States route as: IV (intravenous)
- Includes the type of fluid/solution
- Includes any additives
- Indicates the infusion rate or volume over time
- For example: D5 0.45%NS IV at 100 mL/hr or D5 0.45% 500 mL over 1 hr
Vein Selection for IV Therapy
- Take into consideration: vein size, patient condition, characteristics of solution, rate of solution, and available intravenous access devices
Types of Intravenous Access Devices
- Peripheral
- Central
Peripheral Venous Access
- Short over-the-needle catheters
- Steel-winged devices
- Midline catheters
IV Catheter Gauge
- A smaller gauge number indicates a larger diameter or hole
- Size 14G is for trauma and rapid infusion
- Size 16G is for trauma and surgery
- Size 18G is for blood transfusions
- Size 20G is for IV fluids and medications
- Size 22G is for IV fluids and small veins
- Size 24G is for fragile veins and pediatrics
- Size 26G is for neonates
Central Venous Access
- Non-tunneled percutaneous central catheters
- Tunneled catheters
- Implanted ports
- Peripherally inserted central catheters (PICC)
- Intraosseous (IO)
PICC Lines
- A central venous catheter inserted into a vein in the arm
- Can be single or multilumen, nontunneled
- Appropriate for patients needing vascular access for 1 week to 6 months
- Do not use the arm with a PICC line to asses BP or draw blood
Nursing Management of Infusion Therapy: Administration Styles
- Continuous infusion
- Intermittent infusion
- Bolus
- IV push
Routine IV Care
- Follow facility policy
- Schedule saline flushing if not administering continuous fluids
- Clean and care for the hub
- Properly apply dressings
- Documentation
Monitoring and Preventing Complications: Fluid Volume Overload/Circulatory Overload
- Monitor fluid status
- Conduct a Physical Assessment
- Monitor I&O
- Monitor weight
- Monitor serum electrolytes
Physical Assessment Findings indicating Fluid Volume Overload/Circulatory Overload
- Increased blood pressure
- Dyspnea
- Wet cough (crackles, rales)
- Increased heart rate
- Distended neck veins
Monitoring and Preventing Complications: Infiltration
- The solution infuses into the tissue surrounding the vein
- Blanched, cool skin at the site, edema, unexpected pain/burning, leaking of fluid
- Extravasation is infiltration of a vesicant
- Stop IVF immediately if extravasation occurs
Monitoring and Preventing Complications: Phlebitis
- Inflammation of the vein
- Pain and erythema along the vein
- Graded using a 0-4 Phlebitis Scale
- Causes include: chemical, mechanical, or bacterial
- May progress to cellulitis, thrombus or sepsis, needing removal and replacement
Central Line Complications
- Infection
- Loss of patency
- Thrombotic occlusion
- Medication precipitation
- Air embolism
Blood Products
- Whole blood
- Packed Red Blood Cells (PRBCs) - Most common; improve O2 carrying capacity; for trauma, surgeries, and anemia
- Fresh Frozen Plasma (FFP) - Second most common; improves blood clotting
- Platelets - For thrombocytopenia/pre-surgery, especially if the patient is on platelet inhibitors
- Albumin - Volume expander; Used to improve protein levels
Compatibility
- O is a universal donor
- AB is a universal recipient
Rh Factor and Blood Transfusions
- Rh-positive individuals can receive either Rh-positive or Rh-negative blood
- Rh-negative individuals can only receive Rh-negative blood
Pre-checks for Administering Blood Products
- Verify the order
- Obtain or verify the consent (signed by provider and patient)
- Ensure type and cross match is complete
- Confirm a patent and appropriately sized IV is in place
- Gather necessary supplies and equipment
- Determine if the patient needs pre-medication
Actions at the Bedside for Administering Blood Products
- Two-nurse verification to confirm blood to order and patient to blood which includes ABO & Rh and expiration dates
- Patient assessment including vital signs, lung sounds, and discussion of the transfusion
- Patient education on signs and symptoms of concern, including fever, chills, and shortness of breath
Start of Infusion for Administering Blood Products
- Start the infusion slowly (2mL/min or 120 mL/hr for the first 15 minutes)
- Remain at the bedside for the first 15 minutes
- Take the first set of vital signs at 5 minutes
- Monitor for any signs of a reaction, such as fever, itching, or dyspnea
- Set the infusion rate per order, ensuring it does not exceed 4 hours (or follow hospital policy)
Potential Transfusion Reactions
- Acute hemolytic reaction
- Febrile nonhemolytic reaction
- Allergic reaction
- Circulatory overload
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