The nurse is determining if any of the patients require peripheral IV dressing change. The date is 2/22 and the time 0900. The agency use a commercially engineered catheter stabilization device with its own transparent dressing. Which of the following patients would require a peripheral dressing change? (SATA) A patient:
With a wet peripheral IV dressing after bathing.
Whose manufactured stabilization device is loose.
The nursing assistive personnel reports to the nurse that the patient appears to be very short of breath. The nurse assesses the patient and determines the patient is experiencing fluid volume excess (FVE). The nurse notes that 500 mL of IV fluids have infused in the last hour, rather than the prescribed 50 mL/hr. What action should the nurse take first?
Discontinue the IV.
A nursing student has initiated and regulated an IV in the skills lab but is now assigned to a patient in a clinical setting. The patient has an IV of 0.9% normal saline infusing at 50 mL/hr. Which of the following indicates correct understanding regarding managing IV fluid administration?
When using microdrip tubing, milliliters per hour equals gtt per minute.
At 0800, a 1000 mL bag D5 1/2NS is hung. The flow rate is 125 mL per hour and the drop factor is 60 gtt per mL. At 1200 (noon), 550 mL is left. What action should the nurse take to make sure the IV completes on time?
Increase the rate of 138 mL/hr
A student nurse is changing the intravenous (IV) line tubing of a patient's peripheral IV. Which action, if made by the student nurse, indicates that further instruction is needed? The student nurse: SATA
Connects the new tubing to the patient and then removes any air bubbles.
Opens the clamp so that the flow rate is wide open to reduce the time of priming the tubing.
The nurse is changing the IV fluids and tubing. Which of the following are actions the nurse can take prevent complications and/or keep the electonic infusion device (EID) from alarming? SATA
Place the roller clamp in the on position after the fluids and primed tubing are connected to the patient and the EID.
Change intermittent tubing every 24 hours and change the administration set tubing at same time as fluid container when possible.
When priming the tubing, have roller clamp in off position, fill drip chamber one-half full and slowly release the roller clamp to prime the tubing.
A patient has been admitted with heart failure. The health care provider's order state to administer normal saline at 50 mL per hour. An hour later, the nurse finds that 150 mL have infused. What priority assessments should the nurse make? SATA
Auscultate lungs for crackles
Check pulse for tachycardia
Assess respiratory pattern for evidence of dyspnea
Inspect lower extremities for edema