The nurse is caring for a patient with a peripheral IV who tells the nurse that the IV site
is painful and puffy. What is the nurse's best action?
a. Discontinue the IV and start another line in the other arm.
b. Aspirate to check for blood return and flush the IV with sterile saline.
c. Clean the IV site with chlorhexidine and apply a new sterile dressing.
d. Change the IV tubing and administer prescribed pain medication.
The nurse is caring for a patient who has a central venous catheter (CVC). Which
nursing intervention is the most important for the nurse to include in the patient's plan of
care?
a. Carefully document all assessments of the catheter site.
b. Use strict sterile procedure when performing dressing changes.
c. Label each new dressing with the date, time, and nurse's initials.
d. Ensure that the CVC is discontinued as soon as possible.
The nurse is caring for a patient who is to receive intermittent bolus doses of phenytoin
(Dilantin) through the IV line. Which intervention has the highest priority when
administering this medication?
a. Check for blood return and compatibility prior to administration.
b. Use a new IV tubing set each time the medication is administered.
c. Document the date, time, and nurse's initials after each dose is administered.
d. Use sterile gloves when drawing up and administering the medication.
The nurse is caring for a patient who is to receive a transfusion of packed red blood
cells. The patient has a 22-gauge IV in his arm with 0.9% normal saline infusing. What
intervention will the nurse perform before obtaining the packed red blood cells from the
blood bank?
a. Identify the blood group, type, and expiration date with another nurse.
b. Insert an 18- or 20-gauge angiocatheter into the patient's other arm.
c. Program the IV infusion pump so that the transfusion will complete within 4 hours.
d. Obtain a new microdrip tubing and extension tubing from the clean utility room
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