NUR 337 Midterm Exam Questions With Verified Solutions.
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Course
NUR 337
Institution
NUR 337
Should you shave or clip hair of an IV site before starting an IV? - Answer Clip! Shaving the hair may cause tiny abrasions which could increase the risk for infection.
Which anatomical part should be avoided in the elderly when starting an IV? - Answer The dorsal part of the hand because ...
NUR 337 Midterm Exam Questions With
Verified Solutions.
Should you shave or clip hair of an IV site before starting an IV? - Answer Clip! Shaving the hair may
cause tiny abrasions which could increase the risk for infection.
Which anatomical part should be avoided in the elderly when starting an IV? - Answer The dorsal part
of the hand because the veins are susceptible to damage and the hand can be bumped easily.
What may be used instead of a tourniquet with the elderly? - Answer Blood pressure cuff
An adult patient developed a complication with his IV and it had to be removed, yet continued IV fluids
were needed. Which site would be most appropriate for the nurse to choose?
a. Proximal to the previous IV site.
b. Distal to the previous IV site.
c. In the antecubital fossa.
d. In the foot. - Answer A (The most appropriate site would be proximal to the previous site or in the
opposite extremity if possible. The foot in an adult should be avoided. Having the IV catheter located in
the antecubital fossa would limit the patient's movement.)
List the steps taken to inset a peripheral intravenous device. - Answer 1. Verify order on patient chart,
unit standing orders/protocol. Review facility policy.
2. Assemble equipment including the selection of the appropriate gauge catheter
3. Provide for privacy. Perform hand hygiene.
4. Introduce self to patient/client. Identify patient/client with 2 identifiers & MRN. Explain purpose and
procedure to the patient/client. Raise bed to a comfortable working height.
5. Organize and prepare equipment including priming the extension set with saline. Ensure sterility of
equipment. Place nearby in the sterile package.
6. Adhere to principles of asepsis and utilize standard precautions.
,7. Inspect potential insertion sites to select vein. Be aware of your particular pt. (their age, where they
have had previous successful IV's inserted, cardiovascular diseases or other complicating diseases that
may affect IV insertion).
8. Apply tourniquet 2-6 inches above the selected site to occlude venous flow. Leave on no more than
one minute. May remove and then reapply after cleansing the insertion site. Prevent venospasm.
9. Don clean gloves, apply tape to glove for later use, and cleanse insertion site with antimicrobial barrier
according to manufacturer's guidelines for how to and amount of time to cleanse. Refrain from touching
the cleansed site. Allow to air dry according to agent used. (A facility may stock 10% povidone-iodine or
70 % alcohol, or 2% aqueous chlorhexedine gluconate (Chloraprep), If chlorhexidine cleanse area with
repeated back-and-forth strokes of the applicator for 30 second and let dry for approximately 2 minutes.)
Chlorhexidine reduces the skin surface bacteria. Allowing it to dry completely promotes maximum
bactericidal effectiveness.
10. Anchor vein by stretching patient's skin distal to the site with thumb or forefinger far enough away
(1-2 inches) from the site so that the
At what angle should an IV catheter puncture the skin and vein during insertion in a middle-aged adult?
a. 10- to 30-degree angle
b. 45-degree angle
c. 90-degree angle
d. 5- to 10-degree angle - Answer A (The skin and vein should be punctured with the catheter held at a
10- to 30-degree angle. The angle of insertion may be decreased when inserting the catheter into an
elderly patient to avoid rolling the vein or puncturing through the vein. Superficial veins require a smaller
angle, and deeper veins require a greater angle. A 45-degree angle may be used for administering a
subcutaneous injection. A 90-degree angle may be used to administer an intramuscular injection.)
When should the tourniquet be released a second time during the procedure for insertion of a
peripheral intravenous device?
a. After the catheter is secured with tape or a transparent dressing
b. Immediately after the catheter punctures the skin
c. Immediately after observing a "flashback" of blood in the catheter
d. After a "flashback" of blood is observed and the catheter has been advanced off the stylet - Answer
D (The tourniquet is released after a "flashback" of blood is observed in the catheter's flashback
chamber and the catheter has been advanced off the stylet until the catheter hub rests at the
, venipuncture site. Releasing the tourniquet restores blood flow to the arm. If the tourniquet is released
too soon, the vein will collapse, making insertion more difficult.)
The nurse is preparing an IV infusion prior to initiating an IV. The nurse removes the protective sheath
covering the tubing insertion spike and accidentally touches the spike. What is the nurse's best action at
this time?
a. Wipe the insertion spike with an alcohol swab, allow to dry, and insert into opening of IV bag.
b. Insert spike into opening of IV bag and compress the drip chamber and release, allowing it to fill to
one-half full.
c. Discard IV tubing and obtain a new one.
d. Discard IV tubing and fluids and obtain new supplies. - Answer C (The insertion spike has been
contaminated. To reduce the likelihood of infection, the nurse should discard the tubing and obtain a
new one.)
The nurse knows to monitor the patient's IV site for signs of phlebitis. Why is it most important to
discontinue the IV site if phlebitis is evident?
a. Because it will cause the patient pain.
b. In order to prevent the spread of infection to the other extremity.
c. Phlebitis will eventually result in infiltration.
d. Phlebitis can be dangerous because blood clots can occur. - Answer D (Phlebitis can be dangerous
because blood clots (thrombophlebitis) can occur and in some cases may result in emboli. This may
result in permanent damage to veins as well as resulting in extended facility care.)
Which of the following would be consistent with infiltration? (Select all that apply.)
a. Redness
b. Cool to touch
c. Warm to touch
d. Swelling around insertion site
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