Author Question: A nurse is caring for a patient with a peripheral IV line located in the right forearm. The patient ... (Read 46 times)

rlane42 · **on:** Jul 23, 2018

A nurse is caring for a patient with a peripheral IV line located in the right forearm. The patient informs the nurse that the IV site is burning. Upon assessment the nurse determines that the IV solution has infiltrated.

What site(s) is/are appropriate to consider when restarting the IV line? Select all that apply.
a. Left hand
b. Right wrist
c. Right antecubital area
d. Right saphenous vein

Question 2

A man was involved in a motor vehicle accident yesterday. He is to be sedated for more than 2 weeks while breathing with the assistance of a mechanical ventilator.

Which of the following would be an appropriate nursing diagnosis for him at this time?
a. Risk for Infection related to subcutaneous injuries
b. Risk for Impaired Skin Integrity related to immobility
c. Impaired Tissue Integrity related to ventilator dependency
d. Impaired Skin Integrity related to ventilator dependency

prumorgan · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

A, C
When restarting an IV line after an infiltration, you must restart above the site of infiltration. As a result, the right antecubital area is correct. The opposite extremity (e.g., left hand) may also be used. The right saphenous vein is incorrect because that vein is located in the leg. The leg should be used as a last resort for an IV site. The primary care provider should be notified if a leg is being considered as an IV site.

Answer to Question 2

B
This patient is at Risk for Impaired Skin Integrity because he is being kept in a sedated state. Thus, he is unable to turn himself to relieve pressure. There is no mention of subcutaneous injuries, ruling out Risk for Infection related to subcutaneous injuries. Impaired Tissue Integrity and Impaired Skin Integrity are also incorrect because there is no supporting evidence for these nursing diagnoses.