While assessing a client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?
a. Grade 3 phlebitis at IV site
b. Infection at IV site
c. Thrombosed area at IV site
d. Infiltration at IV site
Question 2A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?
a. Apply cold compresses to the IV site.
b. Elevate the extremity on a pillow.
c. Flush the catheter with normal saline.
d. Stop the infusion of intravenous fluids.
Question 3A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention?
a. The initial site dressing is 3 days old.
b. The PICC was inserted 4 weeks ago.
c. A securement device is absent.
d. Upper extremity swelling is noted.
Question 4A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?
a. The catheter has been in place for 20 hours.
b. The client has poor vascular access in the upper extremities.
c. The catheter is placed in the proximal tibia. d.
The client's left lower extremity is cool to the touch.
Question 5A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?
a. Redness at the catheter insertion site
b. Report of headache and stiff neck
c. Temperature of 100.1 F (37.8 C)
d. Pain rating of 8 on a scale of 0 to 10
Question 6A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?
a. Administer a sublingual nitroglycerin tablet.
b. Prepare to assist with chest tube insertion.
c. Place a sterile dressing over the IV site.
d. Re-position the client into the Trendelenburg position.
Question 7A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this client's teaching?
a. Avoid carrying your grandchild with the arm that has the central catheter.
b. Be sure to place the arm with the central catheter in a sling during the day.
c. Flush the peripherally inserted central catheter line with normal saline daily.
d. You can use the arm with the central catheter for most activities of daily living.
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