IV THERAPY CH18 P2: INTRAVENOUS THERAPY

Intravenous therapy

-infusion of medication or other liquid therapeutic agents directly into the venous system

IV therapy reasons

-may be needed to maintain fluid volume if patient is not taking in fluids/nutrition po

-replacement for fluid loss through prolonged n/v

-used to give medications, blood/blood products, nutritional support

What can IV routes provide?

-faster absorption and more rapid distribution of medication, solutions, or nutrients

-can be short term or long term

LPN scope of practice: IV therapy

-basic IV needle insertion

-adjusting IV flow rate

-administering IV medications

-the RN is responsible for supervising infusion therapy

Special Considerations for Patients Receiving Intravenous Thearpy

-avoid using sites that are easily moved or bumped with young children and older adults

-superficial veins are hard to locate in obese pateints

-avoid using ext. with circulatory, neurologic impairment, or the dominant

-use 16-18 gauge catherter to administer fast or thick solutions (blood)

-critically ill patients need more monitoring

-solutions <100 mL remaining, must have a new bag on standby

-fragile veins or engorged veins should not be tighten with tourniquet (use BP cuff)

-use direct approach for large veins; indirect for small, fragile veins

-do not attempt a puncture more than twice

Central Venous Access Device

-IV therapy needed over a long term (weeks or months)

-is inserted by a NP or physician

Why was CVADs developed?

-to address the difficulties caused by repeated access to the venous system

-provide safer access to the venous system and avoids the dangers of multipule punctures (vein sclerosis, bruising, infection, pain)

-used for administration of various fluids (chemotherapy, parenteral nutrition, blood samples, daily lab test, and hemodialysis

CVAD Categories

-tunneled central venous catheters (CVCs)

-percutaneous CVCs

-implanted infusion ports

Where can percutaneous CVCs and tunneled CVCs be inserted?

-percutaneous CVCs can be inserted at the bedside

-tunneled CVCs are inserted in the operating room

Two most common complications of implanted CVCs

-infection and occlusion of the catheter cannula

-are usually preventable by appropriate dressing changes and heparinization of the ports

peripherally inserted central catheter (PICC)

-alternative to CVCs for patients requiring IV access beyond the length of time that peripheral lines can be maintained (7 days - 3 months)

-specially trained nurses or HCP insert these

-inserted into the cephalic or basilic vein in the upper arm or subclavian vein

What is the diiference between PICC lines and CVCs

-PICC lines pose less risk of pneumothorax, hemothorax, air embolisms, phlebitis, and infiltration

-are less expensive to maintain

What problems come with PICC lines

-clotting

-leaking from catheter

-migration of catheter

-catheter beakage

PICC line gauges

-16-24 gauge

-40-65 cm

Checkpoints for IV sites

-inspect and palpate the site for edema, erythema, induration, heat, and discomfort

-burning sensation often means the solution is irritating the vein; slow the infusion rate

-compare the hand or arm with the opposite hand or arm

Symptoms of fluid oveload

-dyspnea

-dec. O2 sat

-rapid weak pulse

-cough

-disorientation

-inc. BP

-crackles

-pitting edema

-wt. gain

slow infusion rate and notify HCP if overload is suspected

Infiltration

-seepage of nonirritating solution or medication into tissue surrounding the vessel

-most common complications of IV therapy; caused by dislodgement of IV cannula

Phelebitis

-an inflammation of the vein

-results from mechanical, chemical, or bacterial irritation of the vessel

-prevention includes using large veins for hypertonic solutions, use of the smallest gauge cannula, rotating IV sites per 72hr, and use CVCs or PICCs for long term therapy

Septicemia

-occurs when microorganisms enter the blood, may occur as a result of IV therapy when poor aseptic technique or contaminated equipment is used during IV-line insertion

S|S of speticemia

-fever

-chills

-lethargy

-pain

-HA

-n/v/d

INS recommended solution change

-q24h or sooner is bag is empty

Facility recommenced solution change

-q72-96h for continuous infusions

-q24h for intermittent infusions or infusions through an injection port

IV solution care for showering

-never DC the tubing

-thread through sleeve of garment

-cover site and dressing with water-resistant covering

When and why can a blood transfusion be ordered?

-when there is a problem with the amount of blood circulating in the body, any of the blood components

-to replace blood volume, preserve oxygen-carrying capacity, inc. coagulation capabilities

What is the hemoglobin level at which the HCP will order a blood transfusion

-below 8g/dL

Autologous Blood Transfusions

-can be given with blood lost during surgery or after traumatic injury

In the case that some does not accept blood transfusions due to religion; what can be used in its place?

-plasma expanders

What MUST be done before a blood tansfusion

-type and cross-matching test

-VERY STRICT identification and labeling is needed for these procedures

When can blood transfusion reactions occur?

-at anytime but usually within the 1st 15 min

when should blood bags be disposed of?

-after 4 hrs; after 2-4 infusion

What solution should be used as the primary infusion at the start of a blood transfusion?

-0.69% NS

How long should the nurse stay with the patient when starting a blood transfusion?

-first 15-20 min

What should be done at the completion of a blood transfusion?

flush tube with NS

Signs of blood transfusion reaction

- patient complaint of "not feeling right"; sense of impending doom

-chills

-fever

-lower back pain

-pruritus

-low. BP

-n/v

-dec. urine output

-back pain

-CP

-wheezing

-dyspnea

Hemolysis

-delayed transfusion reaction that can occur weeks after transfusion that leads to the destruction or breakdown of red blood cells; development of antibodies to the blood

Circulatory Overload

-a complication of blood transfusions ; when the patient is unable to handle the additional fluid from the transfusion and develops a cough, frothy sputum, cyanosis, and inc. BP

Nursing Implications IV therapy

-data collection helps the nurse anticipate the patient's needs for nursing interventions

-patient problems

-compromised blood flow to tissue

-fluid volume overload

-inadequate fluid volume

-Evaluate the interventions by comparing the patient's responses to the expected outcomes of the established goals. Be prepared to revise the plan of care based on the evaluation findings.

-• Obtain daily weight and monitor. Be sure to weigh the patient using similar conditions as noted above.

• Obtain patient's vital signs. • Measure all routes of intake and output. • Auscultate for abnormal lung sounds. • Check oral mucous membranes for dryness or moistness.

• Check tissue turgor for tenting or edema. • Monitor serum electrolyte levels.

A nurse is preparing to administer IV therapy to a patient who is unable to take oral fluids. What primary function does IV therapy serve in this situation?

A) Replace lost electrolytes

B) Provide rapid medication distribution

C) Support nutritional needs

D) Maintain fluid intake and output

Answer: C) Support nutritional needs

Rationale: IV therapy serves the purpose of providing nutritional support when a patient cannot take in oral fluids or nutrients. This method allows for the infusion of essential nutrients directly into the venous system.

Which type of catheter is commonly used in contemporary IV therapy, featuring a metal needle extending beyond a soft catheter?

A) Butterfly catheter

B) Over-the-needle catheter

C) Central venous catheter

D) Winged infusion set

B) Over-the-needle catheter

Rationale: Over-the-needle catheters are commonly used in IV therapy today. They consist of a metal needle that extends past the tip of a soft catheter, allowing for venipuncture followed by withdrawal of the needle, leaving the soft catheter in place.

Which statement regarding IV administration aligns with legal guidelines?

A) IV administration should be performed by any licensed healthcare provider.

B) Specially trained nurses must meet legal qualifications for IV administration.

C) IV administration legality varies based on hospital guidelines.

D) IV administration legality is determined by federal regulations.

B) Specially trained nurses must meet legal qualifications for IV administration.

Rationale: The legal guidelines for IV administration are determined by each state's nurse practice act. Specially trained nurses who meet the legal qualifications and facility guidelines should be involved in IV administration

What is the primary advantage of the IV route in medication administration compared to oral administration?

A) Slower absorption rate

B) Limited medication distribution

C) Delayed therapeutic effect

D) Faster absorption and rapid distribution

D) Faster absorption and rapid distribution

Rationale: The IV route offers faster absorption and more rapid distribution of medications, solutions, or nutrients compared to oral administration, leading to quicker therapeutic effects.

When should a nurse check the health care provider's order before initiating IV therapy?

A) After venipuncture

B) After assembling equipment

C) Before inserting the IV needle

D) After readying the IV equipment

C) Before inserting the IV needle

What condition might necessitate the use of IV therapy in a patient?

A) Digestive issues

B) Respiratory distress

C) Increased oral intake

D) Prolonged nausea or vomiting

D) Prolonged nausea or vomiting

Rationale: IV therapy might be necessary to replace fluid lost through prolonged nausea or vomiting when the patient is unable to take in fluids orally.

Which IV catheter type is most frequently used for venipuncture today?

A) Winged infusion set

B) Central venous catheter

C) Butterfly catheter

D) Over-the-needle catheter

D) Over-the-needle catheter

Rationale: Over-the-needle catheters are the most commonly used IV catheters today. They offer ease of use for venipuncture and subsequent administration of fluids or medications.

In IV therapy, what determines the selection of the venipuncture needle and catheter?

A) Patient's age

B) Solution to be infused and vein condition

C) Medication potency

D) Size of the IV bag

: B) Solution to be infused and vein condition

Rationale: The choice of the venipuncture needle and catheter is based on the solution to be infused and the size and condition of the patient's veins to ensure appropriate administration.

Which primary function does IV therapy serve in a patient unable to take in oral fluids or nutrients?

A) Maintain electrolyte balance

B) Replace blood products

C) Support nutritional needs

D) Manage respiratory distress

C) Support nutritional needs

Rationale: IV therapy is crucial in providing nutritional support to patients who cannot take in oral fluids or nutrients due to various conditions or illnesses.

What legal guidelines determine the involvement of healthcare providers in IV administration?

A) Hospital policies

B) Federal regulations

C) State nurse practice acts

D) International guidelines

C) State nurse practice acts

Rationale: The legal guidelines for IV administration are determined by each state's nurse practice act, outlining the qualifications and guidelines for healthcare providers involved in IV therapy.

Which action is crucial to prevent air embolus during IV therapy?

A) Inverting injection ports

B) Evaluating patient's veins

C) Selecting a nondominant arm for infusion

D) Priming tubing to remove air

D) Priming tubing to remove air

Rationale: Priming tubing helps to prevent air from being forced into the patient's circulatory system, which could cause an air embolus and potential fatality.

What primary purpose does a central venous access device (CVAD) serve in long-term IV therapy?

A) Preventing vein sclerosis

B) Minimizing pain during venipuncture

C) Safely accessing the venous system

D) Reducing redness and swelling at the infusion site

C) Safely accessing the venous system

Rationale: CVADs provide a safer and more sustainable method of accessing the venous system over extended periods, avoiding complications associated with repeated venipunctures.

Which statement regarding CVADs is accurate?

A) Tunneled CVCs are commonly inserted at the bedside.

B) Implantable infusion ports require general anesthesia during insertion.

C) Percutaneous CVCs are primarily used for hemodialysis.

D) Groshong catheters typically have triple lumens.

A) Tunneled CVCs are commonly inserted in the operating room

Rationale: Percutaneous CVCs are typically inserted at the bedside, while tunneled CVCs are commonly inserted in the operating room.

What are the primary complications associated with implanted CVCs?

A) Swelling and redness at the infusion site

B) Vein sclerosis and bruising

C) Infection and occlusion of the catheter

D) Skin irritation and pain

C) Infection and occlusion of the catheter

Rationale: The most common complications of implanted CVCs include infection and occlusion of the catheter cannula.

What is the significance of heparinization in the context of CVADs?

A) Preventing vein sclerosis

B) Reducing pain during infusion

C) Preventing catheter occlusion

D) Minimizing redness at the insertion site

C) Preventing catheter occlusion

Rationale: Heparinization of ports helps prevent occlusion of catheters, a common complication associated with CVADs.

When might a percutaneous CVC be inserted?

A) During chemotherapy

B) During daily laboratory tests

C) During hemodialysis

D) At the patient's bedside

D) At the patient's bedside

Rationale: Percutaneous CVCs are often inserted at the bedside, providing a convenient method for accessing the venous system

Which patient education component is essential regarding CVADs?

A) Initiating infusions and performing dressing changes

B) Performing daily laboratory tests

C) Evaluating vein conditions for possible CVC insertion

D) Reducing pain during venipuncture

A) Initiating infusions and performing dressing changes

Rationale: Patients with CVADs need education on how to initiate infusions, heparinize their devices, and perform dressing changes correctly at home.

What is the primary purpose of evaluating a patient's veins before initiating IV therapy?

A) Minimizing redness and swelling at the infusion site

B) Identifying the dominant arm for venipuncture

C) Selecting a suitable vein for cannulation

D) Determining the patient's pain tolerance

C) Selecting a suitable vein for cannulation

Rationale: Evaluating the patient's veins helps in selecting an appropriate vein for cannulation, ensuring successful IV therapy.

What is the advantage of using CVADs in long-term IV therapy?

A) Reducing the need for strict aseptic technique

B) Minimizing the requirement for venipuncture

C) Eliminating the possibility of infection

D) Preventing redness and swelling at the infusion site

B) Minimizing the requirement for venipuncture

Rationale: CVADs minimize the need for repeated venipunctures, reducing complications associated with accessing the venous system over an extended period.

What is the purpose of inverting injection ports during IV therapy?

A) To prevent infection

B) To minimize vein sclerosis

C) To fill them with fluid

D) To reduce pain during infusion

C) To fill them with fluid

Rationale: Inverting injection ports helps to fill them with fluid, ensuring that air is not present and that the infusion can proceed smoothly without introducing air into the circulatory system.

What distinguishes peripherally inserted central catheters (PICCs) from central venous catheters (CVCs) in terms of associated risks?

A) Higher risk of clotting and migration

B) Less potential for pneumothorax and hemothorax

C) Reduced risk of phlebitis and infiltration

D) Increased likelihood of catheter breakage

B) Less potential for pneumothorax and hemothorax

Rationale: PICCs typically pose less risk of pneumothorax and hemothorax compared to CVCs, making them a safer alternative in this regard.

What is a primary advantage of PICCs over peripheral IV lines?

A) Lower risk of infiltration and phlebitis

B) Reduced incidence of catheter breakage

C) Decreased potential for catheter migration

D) Minimal risk of infection

A) Lower risk of infiltration and phlebitis

Rationale: PICCs present a reduced risk of infiltration and phlebitis compared to standard peripheral IV lines.

What complications are associated with PICCs?

A) Air embolisms and pneumothorax

B) Hemothorax and phlebitis

C) Catheter migration and leaking

D) Vein sclerosis and infiltration

C) Catheter migration and leaking

Rationale: Complications related to PICCs include catheter migration, leaking from the catheter, clotting, infection, and catheter breakage.

How does a burning sensation at the IV site typically signify?

A) Adequate infusion rate

B) Appropriate catheter positioning

C) Irritation caused by the solution

D) Normal reaction to IV therapy

C) Irritation caused by the solution

Rationale: A burning sensation usually indicates that the solution being infused is irritating the vein, warranting a potential decrease in the infusion rate as per provider orders.

What is an immediate action a nurse should take if fluid overload is suspected in a patient receiving IV therapy?

A) Increase the infusion rate

B) Notify the charge nurse or healthcare provider

C) Flush the IV line with saline

D) Administer additional fluids

B) Notify the charge nurse or healthcare provider

Rationale: Suspected fluid overload requires prompt action, such as immediately slowing the infusion rate and informing the charge nurse or healthcare provider.

Which symptom suggests potential fluid overload in a patient receiving IV therapy?

A) Increased weight gain

B) Decreased blood pressure

C) Reduced respiratory rate

D) Elevated oxygen saturation

A) Increased weight gain

Rationale: Weight gain could be an indicator of fluid overload in patients receiving IV therapy. Other symptoms may include dyspnea, crackles, increased blood pressure, and a rapid, weak pulse.

What is the significance of comparing the bag contents with the pump readout during IV therapy?

A) Verifying the health care provider's order

B) Ensuring the accuracy of the IV pump

C) Confirming the solution's temperature

D) Checking for air embolisms

B) Ensuring the accuracy of the IV pump

Rationale: Comparing the bag contents with the pump readout ensures that the IV pump accurately reflects the volume of fluid infused, preventing fluid overload or under-infusion.

Why is it essential to monitor IV sites routinely?

A) To check for catheter breakage

B) To confirm the patient's comfort level

C) To identify any potential complications

D) To assess the site's readiness for removal

C) To identify any potential complications

Rationale: Routine monitoring of IV sites allows for the early detection of complications such as infiltration, phlebitis, catheter migration, or leaking from the catheter.

Question: What defines infiltration in the context of IV therapy complications?

A) Movement of the cannula in the vein

B) Seepage of nonirritating solution into surrounding tissue

C) Inflammation of the vein

D) Dislodgment of the IV catheter

B) Seepage of nonirritating solution into surrounding tissue

Rationale: Infiltration is the seepage of a nonirritating solution or medication into the surrounding tissue due to various causes.

What is a key sign indicating infiltration at an IV insertion site?

A) Warmth and erythema

B) Discomfort and burning sensation

C) Edema that subsides quickly

D) Clear visibility of the vein

B) Discomfort and burning sensation

Rationale: Discomfort, burning sensation, blanching, or coolness around the site are indications of infiltration.

What action should a nurse take if infiltration is suspected at an IV site?

A) Tighten the tape over the site

B) Document the degree of infiltration

C) Apply heat to the affected area

D) Increase the infusion rate

B) Document the degree of infiltration

Rationale: Documenting the degree of infiltration is essential for proper nursing interventions and following agency policies regarding care.

A patient receiving IV therapy complains of discomfort and a cool sensation around the IV insertion site. Upon inspection, the nurse notices swelling. What should be the immediate action?

The nurse should loosen the tape over the site, observe for a short time, and document the degree of swelling to determine if infiltration has occurred.

A patient reports a burning sensation around the IV site, and there's visible blanching in the surrounding area. What intervention should the nurse perform?

The nurse should assess for further signs of infiltration, document the observed symptoms, and follow agency policies regarding care of infiltration, potentially discontinuing the IV and reinserting it elsewhere if infiltration is confirmed.

What characterizes phlebitis in the context of IV therapy complications?

A) Seepage of solution into surrounding tissue

B) Inflammation of the vein

C) Dislodgment of the IV catheter

D) Discomfort and burning sensation

B) Inflammation of the vein

Rationale: Phlebitis is an inflammation of the vein caused by various irritations, resulting in classic signs like erythema, warmth, and discomfort

How can phlebitis be best prevented in IV therapy?

A) Use hypertonic solutions in small veins

B) Employ the largest gauge cannula for the solution

C) Rotate IV sites every 72 hours

D) Limit the use of CVCs or PICCs for long-term therapy

C) Rotate IV sites every 72 hours

Rationale: Rotating IV sites every 72 hours is a preventive measure against phlebitis and vein irritation.

What should be included in nursing documentation regarding phlebitis?

A) Patient's response to interventions

B) Presence of discomfort and burning

C) Infiltration degree

D) Cannula dislodgment

A) Patient's response to interventions

Rationale: Documenting the patient's response to interventions helps in assessing the effectiveness of the care provided for phlebitis.

A patient presents with erythema, warmth, and discomfort at the IV site. What should the nurse do initially?

The nurse should assess the severity of phlebitis, document the symptoms present, and initiate nursing interventions according to the agency's policy

During routine monitoring, the nurse identifies signs of phlebitis at an IV site. What interventions should be prioritized?

The nurse should document the phlebitis rating, perform necessary nursing interventions, monitor the patient's response, and reassess as required per the agency's policy and procedure for phlebitis care.

What nursing action should be taken if a patient demonstrates signs of infiltration during IV therapy?

A) Tighten the tape over the insertion site

B) Increase the infusion rate for better circulation

C) Loosen the tape and document the degree of infiltration

D) Apply ice to reduce swelling at the site

C) Loosen the tape and document the degree of infiltration

Rationale: Loosening the tape over the site and documenting the degree of infiltration allows for assessment and potential intervention as per agency policy.

What distinguishes infiltration from phlebitis in IV therapy complications?

A) Burning sensation and discomfort

B) Seepage of solution into surrounding tissue

C) Warmth and erythema at the IV site

D) Inflammation of the vein

B) Seepage of solution into surrounding tissue

Rationale: Infiltration involves the seepage of nonirritating solution into the surrounding tissue, while phlebitis involves inflammation of the vein.

What potential complication might occur due to infiltration in IV therapy?

A) Vein inflammation

B) Catheter migration

C) Vein sclerosis

D) Catheter breakage

D) Catheter breakage

Rationale: Infiltration can lead to catheter breakage as the cannula dislodges from the vein, causing complications

Which preventive measure is recommended to minimize the risk of phlebitis in IV therapy?

A) Using a large gauge cannula for all solutions

B) Employing PICCs for all IV therapies

C) Rotating IV sites regularly

D) Administering hypertonic solutions in large veins

C) Rotating IV sites regularly

Rationale: Rotating IV sites every 72 hours is a recommended preventive measure against phlebitis and vein irritation.

What is a characteristic sign of phlebitis in IV therapy complications?

A) Discomfort and burning sensation

B) Coolness and blanching at the site

C) Dislodgment of the catheter

D) Seepage of solution into surrounding tissue

A) Discomfort and burning sensation

Rationale: Discomfort and a burning sensation are characteristic signs of phlebitis, indicating inflammation of the vein.

How should nursing documentation regarding phlebitis be managed?

A) Record only the observed symptoms

B) Include patient responses to interventions

C) Document only the severity of the phlebitis

D) Omitting any potential nursing interventions

B) Include patient responses to interventions

Rationale: Documenting patient responses to interventions assists in evaluating the effectiveness of care provided for phlebitis.

What is a crucial nursing action if septicemia is suspected in a patient receiving IV therapy?

A) Resume the IV infusion in the same extremity

B) Notify the healthcare provider and discontinue the IV

C) Administer antibiotics immediately without cultures

D) Change the IV solution container and tubing

B) Notify the healthcare provider and discontinue the IV

Rationale: Suspected septicemia due to IV therapy warrants immediate notification of the healthcare provider and discontinuation of the IV to prevent further infection.

How should the nurse proceed regarding IV therapy when septicemia is suspected?

A) Restart the IV in the same extremity using new tubing

B) Save the discontinued IV catheter, tubing, and solution for possible culture

C) Change the IV solution container and tubing promptly

D) Administer antibiotics without obtaining cultures

B) Save the discontinued IV catheter, tubing, and solution for possible culture

Rationale: Saving the discontinued IV components for possible culture helps identify the source of infection and guides appropriate treatment.

What guideline does the INS recommend regarding changing IV solution containers?

A) Change the container every 72 to 96 hours

B) Change the container every 24 hours for continuous infusions

C) Change the container every 48 hours for intermittent infusions

D) Change the container every 24 hours or sooner if the solution is infused completely

D) Change the container every 24 hours or sooner if the solution is infused completely

Rationale: The INS recommends changing the IV solution container every 24 hours or sooner if the solution has been completely infused to reduce the risk of contamination.

What practice helps reduce infection risks during IV therapy?

A) Changing the tubing every 48 hours

B) Disconnecting tubing during clothing changes

C) Changing the IV solution container weekly

D) Changing the IV solution container, tubing, and dressing simultaneously

D) Changing the IV solution container, tubing, and dressing simultaneously

Rationale: Simultaneously changing the IV solution container, tubing, and dressing reduces the risk of introducing bacteria into the system and lowers the chances of site infections.

What precaution should be taken when the patient is allowed to shower with an IV?

A) Keep the IV site and dressing uncovered during showering

B) Use a non-water-resistant covering over the IV site and dressing

C) Ensure the IV insertion site and dressing are protected with a water-resistant covering

D) Change the IV dressing before the shower

C) Ensure the IV insertion site and dressing are protected with a water-resistant covering

Rationale: Protecting the IV insertion site and dressing with a water-resistant covering prevents moisture from compromising the site integrity.

What action should the nurse take if the IV dressing becomes wet or loose after the patient showers?

A) Keep the dressing unchanged until the next scheduled change

B) Reinforce the dressing with additional tape

C) Assess the site and change the dressing if it becomes wet or loose

D) Apply antibiotic ointment to the site

C) Assess the site and change the dressing if it becomes wet or loose

Rationale: Changing the dressing if it becomes wet or loose after the shower helps maintain proper site hygiene and prevents infection.

What primarily determines the necessity of a blood transfusion according to healthcare provider orders?

A) Patient's desire to receive the transfusion

B) Hemoglobin level falling below 8 g/dL

C) Availability of autologous blood

D) Religious beliefs of the patient

B) Hemoglobin level falling below 8 g/dL

Rationale: Most providers order a blood transfusion when the hemoglobin level falls below 8 g/dL, indicating a need to replenish blood volume or oxygen-carrying capacity.

What consideration is crucial when managing patients who reject blood transfusions for religious reasons?

A) Administering plasma expanders as an alternative

B) Consulting with the LPN/LVN

C) Scheduling autologous blood transfusions

D) Discussing transfusion plans with the healthcare provider

A) Administering plasma expanders as an alternative

Rationale: For patients declining blood transfusions due to religious beliefs, plasma expanders may be used as an alternative to fulfill their medical needs.

How should LPNs/LVNs approach blood transfusions based on state regulations?

A) Administer blood transfusions independently

B) Measure baseline vital signs only

C) Monitor the transfusion without administering it

D) Avoid involvement in blood-related procedures

C) Monitor the transfusion without administering it

Rationale: In some states, LPNs/LVNs are responsible for monitoring transfusions but may not administer them. Understanding the scope of practice is crucial for appropriate involvement.

When might autologous blood transfusions be considered for a patient?

A) During a religious observance

B) After a hemoglobin level of 10 g/dL

C) Following surgical procedures or traumatic injuries

D) When plasma expanders are unavailable

C) Following surgical procedures or traumatic injuries

Rationale: Autologous blood transfusions are considered after surgical procedures or traumatic injuries, allowing patients to use their own stored blood if needed.

Why is it important for patients planning autologous blood transfusions to discuss this with their healthcare provider in advance?

A) To verify religious observances

B) To ensure availability of blood components

C) To decide on plasma expander options

D) To allot time for collection and storage

D) To allot time for collection and storage

Rationale: Discussing autologous blood transfusion plans in advance allows time for collection and storage, ensuring availability when needed for surgery or emergencies.

What is the primary purpose of performing a type and cross-matching test before a blood transfusion?

A) To verify the patient's current blood pressure

B) To match the donor's blood type with the recipient's blood type

C) To measure the patient's baseline vital signs

D) To determine the patient's tolerance to the transfusion

B) To match the donor's blood type with the recipient's blood type

Rationale: The type and cross-matching test ensures compatibility between the donor's blood type and the recipient's blood type to prevent adverse reactions during transfusion.

Why is it crucial for nurses to remain with the patient during the initial phase of a blood transfusion?

A) To monitor the patient's oxygen saturation

B) To provide emotional support to the patient

C) To ensure the blood is infused within 2 to 4 hours

D) To detect any immediate transfusion reactions

D) To detect any immediate transfusion reactions

Rationale: Nurses stay with the patient during the initial phase of the transfusion to promptly identify any immediate adverse reactions that might occur.

What time frame is associated with the highest risk of blood cell damage and infection during a blood transfusion?

A) Within the first 30 minutes

B) Beyond 4 hours

C) Within the first 15 minutes

D) After 1 hour

B) Beyond 4 hours

Rationale: The risk of blood cell damage and infection significantly increases after a unit of blood has been infused for more than 4 hours

Why is it important for nurses to use 0.9% normal saline as the primary IV infusion when initiating a blood transfusion?

A) To decrease the risk of allergic reactions

B) To ensure proper blood cell preservation

C) To prevent clotting within the IV line

D) To avoid interactions with dextrose-containing solutions

D) To avoid interactions with dextrose-containing solutions

Rationale: Using normal saline as the primary IV infusion prevents interactions that might occur if dextrose-containing solutions are used, ensuring the stability of the blood product.

What action should be taken if signs of contamination are observed in the blood or blood product bag before a transfusion?

A) Slow down the transfusion rate

B) Report signs of contamination immediately

C) Continue the transfusion as scheduled

D) Dispose of the bag and start a new transfusion

B) Report signs of contamination immediately

Rationale: Signs of contamination observed in the blood or blood product bag should be reported immediately to the appropriate personnel to prevent potential adverse effects.

What should be done at the completion of a blood transfusion regarding IV tubing?

A) Replace the tubing with fresh tubing for the next unit

B) Dispose of the used tubing in the regular trash

C) Reuse the same tubing for subsequent units

D) Flush the tubing with dextrose solution

A) Replace the tubing with fresh tubing for the next unit

Rationale: To minimize the risk of contamination or reactions, fresh tubing should be used for each unit of blood, following facility policy.

What is a crucial aspect of educating patients before a blood transfusion?

A) Discussing potential alternatives to the transfusion

B) Ensuring the patient signs an informed consent form

C) Explaining the importance of frequent urination during the transfusion

D) Advising the patient to avoid monitoring symptoms during the transfusion

A) Discussing potential alternatives to the transfusion

Rationale: Educating patients about the need for the transfusion, potential risks, and alternatives empowers them to make informed decisions regarding their care.

What is the recommended timeframe for monitoring vital signs during and after a blood transfusion?

A) Every 30 minutes during and after the transfusion

B) Every 2 hours during the transfusion

C) Only during the first 15 minutes of the transfusion

D) Every 4 hours after the transfusion

A) Every 30 minutes during and after the transfusion

Rationale: Frequent monitoring of vital signs every 30 minutes during and after the transfusion is recommended to detect or prevent transfusion reactions.