A nurse responds to an IV pump alarm related to increased ...

[MirandaLo]

A nurse responds to an IV pump alarm related to increased pressure. Which action should the nurse take first?
 
  a. Check for kinking of the catheter.
  b. Flush the catheter with a thrombolytic enzyme.
  c. Get a new infusion pump.
  d. Remove the IV catheter.

Question 2

While assessing a client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?
 
  a. Grade 3 phlebitis at IV site
  b. Infection at IV site
  c. Thrombosed area at IV site
  d. Infiltration at IV site

[kkenney]

Answer to Question 1

ANS: A
Fluid flow through the infusion system requires that pressure on the external side be greater than pressure at the catheter tip. Fluid flow can be slowed for many reasons. A common reason, and one that is easy to correct, is a kinked catheter. If this is not the cause of the pressure alarm, the nurse may have to ascertain whether a clot has formed inside the catheter lumen, or if the pump is no longer functional. Removal of the IV catheter and placement of a new IV catheter should be completed when no other option has resolved the problem.

Answer to Question 2

ANS: A
The presence of a red streak and palpable cord indicates grade 3 phlebitis. No information in the description indicates that infection, thrombosis, or infiltration is present.