The nurse discontinues the client's IV prior to discharge. After ...

[waynest]

The nurse discontinues the client's IV prior to discharge. After removing the catheter, which actions by the nurse are appropriate? Select all that apply.
 
  1. Applying pressure to the insertion site until bleeding stops
  2. Examining the removed catheter to ensure that it is intact
  3. Teaching the client to inform the nurse if the site begins to bleed at any time
  4. Holding the client's extremity below the level of the heart if bleeding persists
  5. Covering the venipuncture site with a sterile dressing

Question 2

The nurse is setting up an IV infusion on an electronic infusion pump. After leaving the room, the pump alarms and reads high pressure. Which is the priority action by the nurse?
 
  1. Resetting the pump to resume infusion
  2. Discontinuing the client's IV access and restarting in a different area
  3. Assessing the client's IV site and the tubing for kinks or closed roller clamps
  4. Asking the client if the pump has been tampered with in any way

[Chelseyj.hasty]

Answer to Question 1

Correct Answer: 1,2,3,5

All the actions by the nurse are appropriate except holding the client's extremity below the level of the heart if bleeding persists. The client's extremity should be held above the level of the heart if bleeding persists.

Answer to Question 2

Correct Answer: 3

The nurse should assess the IV site because an infiltrated IV, or a site that is proximal to a joint, can impede infusion. If the IV site appears to be within normal limits, the tubing should be checked for any kinks, closed roller clamps, or any other impediment to infusion. Resetting the pump without performing a thorough assessment could increase the tissue damage if the site is infiltrated. The IV site should not be discontinued if it is intact, so it should be assessed before considering moving the site. Accusing the client of tampering with the pump would not be justified.

[waynest]

TYSM

[kjohnson]

Gracias!