Chapter 13: Infusion Therapy Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9edition

MULTIPLE CHOICE 1.A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next? a. Begin the prescribed infusion via the new access. b. Ensure an x-ray is completed to confirm placement. c. Check medication calculations with a second RN. d. Make sure the solution is appropriate for a central line. ANS: B A central venous access device, once placed, needs an x-ray confirmation of proper placement before it is used The bedside nurse would be responsible for beginning the infusion once placement has been verified. Any IV solution can be given through a central line. DIF:Applying/Application REF: 205 KEY:Vascular access device MSC:Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2.A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first? a. Amount of pressure in fluid container b. Date of catheter tubing change c. Percent of heparin in infusion container d. Presence of an ulnar pulse ANS: D An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased perfusion to the extremity. Assessment of an ulnar pulse is one way to assess circulation to the arm in which the catheter is located. The nurse would note that there is enough pressure in the fluid container to keep the system flushed, and would check to see whether the catheter tubing needs to be changed. However, these are not assessments of greatest concern. Because of heparin-induced thrombocytopenia, heparin is not used in most institutions for an arterial catheter. DIF:Applying/Application REF: 224 KEY:Vascular access device MSC:Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care