The nurse is caring for a patient receiving antineoplastic medications intravenously. The nurse
discovers that the intravenous site is red, edematous, and painful. The nurse knows that
antineoplastic medications are vesicant medications and documents that the patient has
experienced which of the following events?
a. occlusion
b. extravasation
c. phlebitis
d. thrombophlebitis - Answers b
Established standards for routine replacement of peripheral IV catheters and intravenous
administration sets have recommended a maximum of _____ hours to reduce IV fluid
contamination and prevent catheter site complications.
a. 24
b. 48
c. 72
d. 96 - Answers d.
While assessing the patient, the nurse recognizes that special caution should be taken with the
IV infusion because of fluid volume excess when the nurse notes the presence of which
condition?
a. poor skin turgor
b. crackles in the lungs
c. decreased blood pressure
d. dry skin and mucous membranes - Answers b
The nurse needs to specifically prevent air emboli that may result from IV therapy. What should
the nurse make sure to do to prevent air emboli?
, a. use a needleless system
b. prime the tubing completely
c. check for medication compatibility
d. select a larger-gauge needle or catheter - Answers b
What should be the next action by the nurse, once an over-the-needle catheter (ONC) has been
inserted through the skin and into the vein?
a. loosen the stylet for removal
b. check for blood return in the flashback chamber
c. stabilize the catheter and release the tourniquet
d. advance the catheter until the hub rests at the insertion site - Answers b
What should the nurse do once she recognizes that the patient has phlebitis at his IV site?
a. reduce the flow rate
b. elevate the affected extremity
c. place a moist warm compress over site
d. adjust the additive in the current IV - Answers c
What should the nurse do upon noting bleeding around a dressing at an IV insertion site?
a. discontinue IV
b. assess insertion site
c. leave the dressing intact but reinforce it
d. elevate and apply warm compresses to the extremity - Answers b
Which patient would a nurse anticipate would be a candidate for a peripherally inserted central
catheter (PICC)?