Ch.9 Complete Test Bank Infusion Therapy Vascular Devices

Chapter 9: Complications of Infusion Therapy: Peripheral and Central Vascular Access Devices

Multiple Choice

Identify the choice that best completes the statement or answers the question.

1. A nurse is assisting in the placement of a client’s central venous access device (CVAD). The nurse is aware that the major complication that can occur during placement of a central venous access device is:

A. phlebitis.

B. infiltration.

C. fibrin sheath formation.

D. venous thrombosis.

2. A nurse is caring for a client who has a newly implanted port. For which complication, specifically associated with implanted ports, should the nurse observe?

A. Air embolus

B. Occlusion

C. External catheter breakage

D. Displacement of the septum

3. A nurse is caring for a client who has lipid deposits occluding his or her central line. Which declotting agent should the nurse use to clear lipid deposits from a central line?

A. 70% ethanol

B. Hydrochloric acid

C. Sodium bicarbonate

D. Alteplase

4. A client complains to a nurse that his or her I.V. site is “sore.” The nurse notes that the site is red and edematous, but there is no palpable cord or streak. Using the criteria for infusion phlebitis, what should the nurse document as the severity of this phlebitis?

A. 1+

B. 2+

C. 3+

D. 4+

5. A nurse in an intensive care unit is caring for a client who has visible deposits in her central line. Which agent should the nurse select to instill into the catheter in an attempt to dissolve vancomycin deposits?

A. Alteplase

B. 70% ethanol

C. Sodium bicarbonate

D. 0.1% hydrochloric acid

6. A nurse in an intensive care unit is caring for a client who has an intraluminal obstruction of central line due to a thrombotic occlusion. Which declotting agent should the nurse select to remove the blood clots from a central line?

A. Alteplase

B. 70% ethanol

C. 0.9% sodium chloride

D. Sodium bicarbonate

7. A nurse assesses that a client has developed 2+ phlebitis at the site of a current peripheral I.V. infusion. Which action should be the nurse’s first priority?

A. Notify the physician.

B. Start a new line proximal to the old site.

C. Discontinue the I.V. catheter at that site.

D. Apply warm moist packs to the existing I.V. site.

8. A nurse priming an I.V. administration set uncaps the distal end to attach a needleless device. Before attachment, the administration set falls and hits the countertop. Which action should be taken by the nurse?

A. Attach a new needleless device.

B. Change the administration set.

C. Wipe the tubing port with povidone-iodine.

D. Scrub the needleless device with an alcohol swab.

9. A nurse assesses the insertion site of a peripheral I.V. catheter and notes that the site is red, warm to touch, and slightly edematous proximal to the I.V. cannula. The client reports discomfort when the site is touched. The nurse should interpret that these signs are most likely due to:

A. phlebitis.

B. a venous spasm.

C. hypersensitivity to I.V. solution.

D. infiltration of the solution.

10. A client who has a central venous tunneled catheter for administration of chemotherapy presents to a hospital with fever, hypotension, profuse sweating, nausea, and malaise. Based on this information, which condition should a nurse suspect?

A. Local infection

B. Septicemia

C. Phlebitis at the infusion site

D. Compartment syndrome

11. A nurse assesses a client who is receiving an intermittent I.V. infusion of vancomycin hydrochloride. The nurse notes that the I.V. site is warm, edematous, and taut. The nurse also observes pinkish blood return and fluid leaking from the insertion site. Based on this information, which condition should the nurse suspect?

A. Occlusion

B. Septicemia

C. Extravasation

D. Thrombophlebitis

12. A client who has been discharged from a hospital for 48 hours reports pain at a previous infusion site. On inspection of the site, a nurse finds redness and tenderness along the vein. Which condition should the nurse suspect?

A. Extravasation

B. Speed shock

C. Bacterial phlebitis

D. Postinfusion phlebitis

13. A nurse is caring for multiple clients with I.V. access devices. The nurse carefully assesses each client for signs of local complications. For which systemic complication should the nurse observe?

A. Phlebitis

B. Hematoma

C. Speed shock

D. Extravasation

14. A nurse suspects that a client with a peripheral access device is experiencing a venous spasm. Which report by the client should prompt the nurse to suspect this condition?

A. Redness along the vein

B. Cold feeling in the extremity

C. Sharp pain extending from the site of infusion

D. Increased temperature at the peripheral infusion site

15. Which systemic complication of I.V. therapy should a nurse suspect if a client has a fever, chills, malaise, tachycardia, tachypnea, hypotension, and altered mental status?

A. Septicemia

B. Local infection

C. Thrombophlebitis

D. Inflammatory response

16. Upon inspection of a client’s peripheral I.V. site, a nurse notes 2+ phlebitis of the client’s vein. Which action by the nurse is most appropriate?

A. Watch the site and document observations.

B. Flush the cannula with 0.9% sodium chloride.

C. Discontinue the cannula and apply heat to site.

D. Leave the cannula in place and apply heat to the site.

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

1. Upon inspection of a client’s peripheral I.V. site, a nurse notes 3+ phlebitis of the client’s vein. Which action by the nurse is most appropriate? (Select all that apply.)

A. Watch the site and document observations.

B. Discontinue the cannula

C. Elevate extremity slightly.

D. Apply warm compresses after 30 to 45 minutes.

E. Apply cold to the site initially for approximately 30 to 45 minutes.

2. A nurse on a medical-surgical unit is caring for multiple clients. Which clients should the nurse monitor closely for signs of phlebitis because they are at increased risk? (Select all that apply.)

A. A client with burns

B. A client who is immunosuppressed

C. A client receiving total parenteral nutrition (TPN)

D. A client who had multiple I.V. manipulations

E. A client receiving a peripheral IV of D10 in water

3. A nurse attempts to withdraw a blood sample for laboratory analysis from a central venous access device (CVAD) and is unsuccessful due to an occlusion noted when trying to aspirate the blood. What could potentially be causes of this type of occlusion? (Select all that apply.)

A. Catheter migration

B. Fibrin tail that extends from catheter tip

C. The catheter tip pressed up against the vein wall

D. Blood clot formation and lymphedema

E. A kinked IV line or tubing

4. The nurse taking care of a client diagnosed with CHF attempts to draw blood from the CVAD. The client has signs of a mural thrombus. Which symptoms led the nurse to this conclusion? (Select all that apply.)

A. Inability to aspirate blood

B. Resistance to flushing

C. Frequent infusion pump alarms

D. Sluggish infusion

E. Free-flowing blood return on blood draws

Chapter 9: Complications of Infusion Therapy: Peripheral and Central Vascular Access Devices

Multiple Choice

Identify the choice that best completes the statement or answers the question.

1. A nurse is assisting in the placement of a client’s central venous access device (CVAD). The nurse is aware that the major complication that can occur during placement of a central venous access device is:

A. phlebitis.

B. infiltration.

C. fibrin sheath formation.

D. venous thrombosis.