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Which response might the nurse give to nursing assistive personnel (NAP) who reports that the alarm is sounding on a patient's electronic infusion device (EID)?
A. "Assess the IV site for signs of inflammation."
B. "Be sure to change the dressing on the IV
site."
C. "I'll check the IV site and pump."
D. "Turn off the alarm."
C. "I'll check the IV site and pump."
Rationale: The nurse must assess why the alarm is sounding. Assessment may not be delegated to NAP. No aspect of insertion site care or dressing application may be delegated to NAP. The alarm should not be turned off unless the IV infusion is assessed.
How would the infusion of the IV fluids be affected if the tubing were unintentionally dislodged from the chamber of the control mechanism of the EID?
A. The infusion would slow to a "keep vein open" rate.
B. The patient would receive a bolus of fluid.
C. The infusion would continue at the prescribed rate.
D. The flow of fluid would stop.
D. The flow of fluid would stop.
Rationale: The fluid would stop, because an anti-free-flow safeguard on the EID tubing would stop the flow of fluids. An anti-free-flow safeguard stops the flow of fluids in the event of machine malfunction or tubing dislodgement. This important safety feature is required on an EID. The patient would not receive a bolus of fluid, because an anti-free-flow safeguard on the EID tubing would stop the flow of fluids. The infusion would not continue, because an anti-free-flow safeguard on the EID tubing would stop the flow of fluids.
A patient is prescribed 1000 mL of intravenous (IV) normal saline to run over 8 hours. The initial fluid is hung at 0800. How many milliliters of fluid will have infused by 1200?
A. 125 mL
B. 250 mL
C. 500 mL
D. 625 mL
C. 500 mL
Rationale: The patient is to receive 125 mL of fluid every hour. After 4 hours, the patient will have received 500 mL of fluid.
The nurse calculates that the patient is to receive 125 mL of intravenous (IV) normal saline per hour. After programming the infusion pump to deliver at that rate, how would the nurse ensure accurate fluid administration?
A. First verify that the fluid is dripping, and then check the level of fluid remaining in the container every hour.
B. Ask another nurse to assess the programming of the pump.
C. Set the pump alarm to sound when half of the fluid has infused.
D. Check the IV site for complications.
A. First verify that the fluid is dripping, and then check the level of fluid remaining in the container every hour.
Rationale: Verifying that fluid is dripping and then checking every hour to confirm that the correct amount has infused will ensure accurate fluid administration. Asking another nurse to assess the pump's programming will not confirm that the fluid is being infused at the correct rate. Setting the pump alarm to sound when half of the fluid has infused will not confirm that the fluid is being infused at the correct rate. Checking the IV site for complications is appropriate, but doing so will not confirm that the fluid is being infused at the correct rate.
Which information is not necessary for the nurse to include when documenting the use of an EID for an intravenous infusion?
A. Location of the insertion site
B. Time at which the infusion began
C. Patient's pulse and heart rate
D. Hourly
volume flow rate of the infusion
C. Patient's pulse and heart rate
Rationale: It is not necessary to document the patient's pulse and heart rate as part of the IV documentation. The location of the insertion site must be documented. The time at which the infusion began must be documented. The hourly volume flow rate of the infusion must be documented.
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