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NH IV Certification Exam Questions and
Answers
Vascular Access Device (VAD) - Answers -a catheter, cannula, or infusion port which may be designed for repeated access to the vascular system -Peripheral VADs (PVAD) are initiated by Registered Nurses (RN's) after completing the Northern Health Intravenous Training Manual and exam. -Catheters, tubes or devices inserted into the vascular system including veins, arteries, bone marrow Central Venous Access Device (CVAD) - Answers -a venous access device whose tip dwells in the distal one-third of the superior vena cava, with optimal placement being at the Cavoatrial junction. This includes tunneled catheters, non-tunneled (or temporary) catheters, peripherally inserted catheters (PICC), and implanted ports. -All CVADs require a physician's order and shall have documentation of radiological confirmation of tip placement prior to use. -are initiated by Physicians. IV Therapy may be the desired method of Tx...(7) - Answers -1. to provide necessary fluid, electrolyte and caloric intake for the patient unable to take same orally, or when oral intake is contraindicated by a medical condition
- to provide a method for obtaining an immediate action of therapeutic level of a drug
- to administer medications that cannot otherwise be given
- to provide more accurate dosing of medications
- to provide a means to administer blood and/or blood products
- to maintain and/or correct acid-base balance
- to keep a vein open in case of emergency Three characteristics that differentiate veins from arteries - Answers -Arteries:
- Carry oxygenated blood from the heart to the body
- Have thick, elastic muscular walls; no valves
- Blood flows under high pressure = pulse felt Vein:
- Carry de-oxygenated blood from body to heart
- Have thin, non elastic walls; valves, to prevent backward flow of blood.
- Blood flows under low pressure = no pulse felt Formula for computing IV fluid in gtts/min - Answers -[Volume (mL) X Drip Factor (gtts/mL)]/Time in minutes e.g. [500 mL X 10 gtts/mL]/ 60 min = 83.3 gtts/min (84)
IV therapy: Continuous infusion - Answers -use a primary administration set and allow for carefully regulated amounts of fluid over a specific duration -slower infusion over a prolonged period reduces risk of Speed Shock (sudden adverse physiologic reactions to IV meds) & maintains continuous serum levels -can also lessen vein irritation (larger volumes of fluid can be used to dilute the med) -IV sets need to be changed q96hrs (up to 7 days for out-patient Continuous Ambulatory Drug Deliver CADD) and PRN -Disadvantages: --increased risk for incompatibility with med administration by secondary (piggyback) infusion --increase risk for infiltration --reduced mobility for the patient IV therapy: Intermittent infusion - Answers -use a secondary (piggyback) medication set attached to the primary line or medications are infused through a direct IV administration set -IV set is connected to the patient for treatment then disconnected when treatment is complete (add sterile plug to end of set and label with patient identifier) -indicated for meds that require a short administration time with various intervals (i.e. IV antibiotics) -always check patency with sterile saline before administering -med times need to be consistent -IV sets are changed q24hrs when primary line is disconnected from the patient Advantages: --for fluid restricted patients --ambulation without an IV pole Disadvantages: --higher risk of infection (set is connected and disconnected allowing for opportunity of contamination) IV therapy: direct injection - Answers -delivers medication directly into the blood stream aka "IV push" -commonly used for medication administration when no other IV needs (diuretics, analgesics), and when medication can be delivered under 10 min -achieved with direct venipuncture, through a saline locked IV or through an existing infusion line -allows for immediate med effect=close patient monitoring is necessary (cardiac & respiratory) -always follow by a flush of normal saline to flush med out of IV device or access port (5-10mLs for adults, 1-3mLs for paediatrics)=decreases risk of med incompatibilities Potential complications of IV therapy - Answers --solution flow slowing down or stopping (positional IV: device may be lying against the side of the vein, inappropriate level of IV bag, device may be occluded)
-avoid sites distal to previous venipuncture site, sclerosed or hardened cordlike veins, infiltrate site or phlebitis vessels (these sites can cause infiltration of newly place IV catheter and vessel damage) Steps to discontinue an IV - Answers -take care when removing catheter: -maintain position (flush with skin) -apply pressure following removal Signs and Symptoms of an anaphylactic reaction - Answers --decreased LOC -hypoxia (oxygen deficiency) -hives/itchiness -nausea/vomiting -SOB/stridor Tachycardia flushed/red skin -abdominal cramping -hypotension -chest pain/discomfort -swelling (skin/mucous membranes) -feeling of impending doom Mechanisms of anaphylaxis - Answers -Anaphylaxis is initiated by antigens interacting with antibodies on the surfaces of mast cells and basophils. -This interaction makes the mast cells and basophils release certain chemical mediators (SRS-A, histamine, & bradykinin) -These mediators have profound effects on the pulmonary & vascular systems = bronchospasm, increased vascular permeability, & laryngeal edema -These physiologic changes produce a variety of respiratory, cutaneous, & vascular S/S -These S/S can be precursors to shock NH Policy, Procedure & Clinical Practice Standards related to the treatment of an anaphylactic reaction - Answers --Stop causative Agent -Initiate cardiac arrest management (Code Blue or call physician stat)/call 911 -Administer Epinephrine 1:1000 IM into thigh (vastus lateralis) opposite to infecting agent (q5min X max 3 doses, monitor vital signs, --Adult=0.5mg (0.5mL) --*Child=0.01mL/kg up to 0.5mL -Lay in recumbent position (legs elevated) -if hypoxic ensure open airway and administer minimal amt of O2 required to reverse it (SpO2 > or = 92%) --nasal prongs 1-6L/min or face mask 5-10mL/min -administer diphenhydramine IM at a different site to that of Epinephrine --Adult=100mg --Child=2mg/kg up to 50mg (1mL) Pre-requisites for infusion device utilization - Answers --height of the IV fluid container
-IV tubing size -patient flexion -vasospasm of the vein -manipulation of the device or fluid viscosity Rationale for pump use and monitoring requirements - Answers -assist with administration of fluids and/or medications within a controlled process -necessary for pts requiring low hourly rates, at risk for volume overload, with impaired renal clearance, or receiving meds or fluids that require specific hourly volume -type of pump depends on required volume and speed of infusion -audible alarms alert the nurse of pressure change -IV system and flow rate are assessed frequently and systematically to achieve therapeutic outcomes Differentiate between Isotonic, Hypertonic, and Hypotonic solutions - Answers -Isotonic: osmolality similar to blood plasma -cells do not lose or gain fluid -given to expand circulating volume (monitor for fluid overload) -e.g. 0.9% Na Cl (normal saline) will not damage RBCs when used to precede or follow blood transfusion Hypertonic: osmolality greater than blood plasma -help in electrolyte and acid-base imbalances -3% Na Cl are used cautiously to draw water out of the extravascular space into the intravascular space -have potential for complications like: vein irritation, hypovalemia, & interstitial edema Hypotonic: osmolality less than blood plasma -cells draw in fluid and expand -D5%W is useful for treating cellular dehydration & hypernatremia. AVOID in pts. at risk for increase intracranial pressure (ICP) Preparation points for the patient to receive IV therapy (4) - Answers -1. Check physician/ prescriber order in patient's chart
- Complete ten rights
- Determine indication for use of Infusion Device
- Determine rate of infusion Three most commonly used veins for IV therapy - Answers -1. Cephalic Vein (Radial side of arm)
- Basilic Vein (Ulnar side of arm)
- Median cubital vein Documentation of IV initiation in what two forms? 1. (7) 2. (5) - Answers -1. Nursing notes/speciality forms: a. Date/Time b. device size c. site
NH Policy, Procedure & Clinical Practice Standards related to TPN tubing changes - Answers -TPN tubing is changed q24hrs Safety measures related to the administration of TPN (Total Parenteral Nutrition) - Answers -1. Administered on the order of a physician
- Solutions >10% dextrose must be given via CVAD
- Dedicated line (do not mix, do not interrupt - except to flush between infusions, and on physician's orders)
- *Preparation of, and all additives to, are done by Pharmacy, are not stat orders
- Dextrose/amino acid fluids must be started within 24hrs of preparation
- IV catheter extension set with injection cap will be attached to IV device, and changed with IV device and prn
- Tubing changed q24hrs
- D10W will be hung whenever TPN is interrupted and run at the same rate
- A volumetric infusion pump must be used for TPN delivery
- Dextrose/amino acid solution will be filtered Lipid solutions will not be filtered. All in one solutions will be filtered with 1.2 micron filter.
- Patient assessments include: a. Urine testing for sugar & acetone q6h b. BP daily and pen c. Weights - 3 times per week (M-W-F) d. TPR QID
- Consistent rate of administration will be maintained. Do not adjust flow rate greater than 20%. What information is documented related to initiation IV therapy? (7) - Answers -1. Date and Time
- Size and Type of device
- Site location (anatomical name of the vein is preferred)
- Any additive, such as extensions or injection caps
- Number of venipuncture attempts (this includes unsuccessful attempts and if another vein is used)
- Complications, patient response, nursing intervention
- If applicable, patient teaching and evidence of patient understanding Choosing the appropriate IV device - Answers -Smallest catheter in the largest possible vein -adequate blood flow around the catheter is necessary for vessel preservation -pH or osmolality of the infusatn may irritate the Tunica Intima Tips for Vein Selection - Answers --take time to assess both arms for the most appropriate site -IVs in the hand are best for temporary IV access as they interfere wit ADLs -apply moist heat to the arms for 15-20 min to dilate the veins -palpation is an important assessment; do not chose a vein only on visualization
-apply a flat tourniquet, only tight enough to dilate the vein -place arm in a depend position (below level of the heart) -When learning, go to the vein you know you can get. Parenteral Nutrition - Answers -the provision of partial or total nutrient requirements through the venous system TPN (Total Parenteral Nutrition) - Answers -is the provision of nutrient requirements through a central venous access device (CVAD) -indicated where there is an absorption problem in the lower GI -bacteria also love TPN, be careful Electrolytes - Answers -conduct current that's necessary for cell function Sodium - Answers --Influences distribution of body water (with chloride) -maintains appropriate extracellular fluid osmolality (vascular fluid) -helps maintain acid-base balance & nerve-and-muscle-fibre impulse transmission: this is achieved through the kidneys response to fluid intake and sodium loses Hyponatremia: not enough sodium Hypernatremia: too much sodium Hyponatremia - Answers -associated with weakness, muscle spasm, confusion, & headaches -severe cases: seizures & coma can occur -elders at greater risk as they may experience decreased thirst sensation, decreased ability to ask for fluids, and small appetites -treated with 3.0% Saline in symptomatic cases, administered slowly & with extreme caution to avoid intravascular overload & pulmonary edema Hypernatremia - Answers -associated with dry mucous membranes, thirst, flushing, agitation, restlessness, hyperreflexia, mania & convulsions -treated with D5W to replace water losses Potassium - Answers -the main intracellular cation, very important to muscle functioning (including the heart muscle with both rate and contractility) -involved with protein synthesis, & maintenance of acid-base balance, pH, & osmotic pressure in cells hypokalemia: not enough potassium hyperkalemia: too much potassium Hypokalemia - Answers -associated with a decrease in contractility of smooth, skeletal, & cardia muscle=atrial & ventricular arrhythmias, weakness, leg cramps, paralysis, hyporeflexia, ilexes, constipation, N/V Hyperkalemia - Answers -associated with irritability, nausea, diarrhea & paresthesia of the face, tongue, hands, & feet
Hyperphosphatemia: too much phosphorous Hypophosphatemia - Answers -symptoms include confusion, seizures, coma parenthesis, ataxia and speech deficits Additional Precautions (3) - Answers -extra precautions in addition to routine practices that are based on the way organisms are transmitted. -Contact -Droplet -Airborne Transmission Add-ons - Answers -These are devised that include: -stopcocks -extension sets -manifold sets -extension loops -solid cannula caps -injection/access ports -needles or needless systems and filters Antiseptic - Answers -a substance that destroys or stops the growth of micro-organisms on living tissue (i.e. skin) Caps - Answers -provide access to the vascular system for the purpose of medication administration, and/or connectivity of administration sets -may be used to cap unused lumen, or as part of a saline lock -may be of needle free or needle access design Catheter Dislodgement - Answers -movement of the catheter into and out of the insertion site Causes: -inappropriate securement of the catheter -motion of the extremity, neck or shoulder May cause: -occlusion of the catheter and lead to a change in the catheter tip location S/S: -changes in the external length of the catheter -clinical signs of local catheter infection -inability to flush or infuse via the catheter Caudal - Answers -toward the tail or end of the body, away from the head Cephalad - Answers -toward the head Chemical incompatibility - Answers -change in the molecular structure of pharmacological properties of a substance that may or may not be visually observed
Erythema - Answers -Redness of skin along vein track that results from vascular irritation or capillary congestion in response to irritation; may be a precursor to phlebitis Extension sets - Answers -are customized IV tubing which adds length to the administration set, or alternatively may be capped and added to PVAD to create a saline lock -may be added to CVAD for line maintenance/access -are considered part of the device if added under sterile conditions at time of CVAD insertion Implanted Vascular Access Device or Implanted Port - Answers -a catheter surgically placed into a vessel or body cavity and attached to a reservoir located under the skin Incompatible - Answers -incapable of being mixed or used simultaneously without undergoing chemical or physical changes or producing undesirable effects Irritant - Answers -agent capable of producing discomfort or pain at the venipuncture site or along the internal lumen of the vein Midline catheter - Answers -a device that is inserted via the antecubital veins and advance into the veins of the upper arm but not extending past the axilla (usually about 20cm in length) Milliosmoles (m0sm) - Answers -One-thousandth of an osmole -osmotic pressure equal to one-thousandth of the molecular weight of a substance divided by the number of ions that the substance forms in a litre of solution Occluded - Answers -blocked because of precipitation of infusate, clot formation or anatomic compression Osmolarity - Answers -number of osmotically active particles in a solution pH - Answers -degree of acidity or alkalinity of a substance Phlebitis - Answers -inflammation of a vein (rate by standard scale) -may be accompanied by: --pain --erythema --edema --streak formation --and/or palpable cord Peripherally Inserted Central Catheter (PICC) - Answers -soft, flexible, central venous catheter inserted into an extremity and advanced until the tip is positioned in the lower third of the superior vena cava
- Right to refuse and drug approach
- Right Evaluation (drug-drug interaction)
- Right Education and Information 3 checks - Answers -1. check when you're taking out the medication from the cabinet.
- check after you've taken out all the medication from the cabinet and put the drawer back.
- check at the bedside right before you give the patient the medication. NH Policy, Procedure & Clinical Practice Standards related to Blood, or blood products - Answers -1. Documentation of informed consent is completed prior to administering any blood product.
- RN, LPN, SN, NP, RM and physician can witness the signature on the "Administration of Blood Products" form, ensures a discussion took place between patient and the physician regarding treatment
- No documentation or understanding, RN notifies physician and does not initiate an elective transfusion until situation is resolved.
- Only a physician can order a blood product
- Refusal of blood products obtained by the physician only
- Appropriate documentation must be entered into health record prior to emergency treatment
- Group and Screen can be initiated without a consent form
- All blood products must be double checked in presence of patient by 2 trained clinicians competent in the transfusion administration process. including: --verification of patient name & unique identifiers on physician order sheet --issued blood product --blood product tag --Blood Product Transfusion Record form --patient identification band and/or patient Transfusion Medicine Services (TMS) Identification Band
- All identifying info remains attached to blood product bag until completion of infusion
- Specimens collected for purpose of blood grouping and screening must be labelled in presence of the patient at time of draw (patient should spell name and date of birth)
- Blood products that have been cross-matched and/or prepared by another hospital must be sent directly to TMS for inspection
- Gravity fed administration of red cells is the preferred method for elective transfusion
- Mechanical infusion may be preferred for patients at risk for fluid overload
- Paediatrics & Neonates: mechanical infusion is preferred
- Rate of infusion is ordered by the physician
- N/S is the only IV fluid compatible with blood products except D5W w Administration of blood products - Answers -1. Confirm physician's order
- Obtain consent for transfusion of blood products
- Assess or initiate venous access (initiate primary infusion of N/S or D5W for IVIG
- Complete initial set of vital signs, incl. SaO2 (complete and document cardio and resp. assessment, if necessary)
- Obtain blood product from TMS
- Compare the Blood Product Transfusion Record form with the Patient Record/Chart and verify: -Patient's first and last name -Patient's MRN number -Physician order -Consent -Patient ABO group
- Compare the TMS documentation with the product label and attached Blood Product tag and verify: -Patient's first and last name -Patient's MRN number -TMS ID number -Type of Blood Product and ABO blood grouping -serial number (7 or 13 digits) -Blood Product expiry date and time -any special requirements -Cross-match expiry date (red cells only)
- Final verification is completed by the same 2 staff members above in the presence of the patient. Compare the patient's first and last name and MRN number using all of the following: -Patient ID band -TMS ID wristband -Blood Product Transfusion Record form -Attached Blood Product compatibility tag and label -Ask patient to spell their first and last name, and state their date of birth
- Confirmed? Do not remove from presence of patient
- Gently invert Blood Product 5-10 times. Spike the bag and prime the Blood Product administration set. (disconnect N/S infusion and connect Blood Product)
- N/S infusion remains at bedside as "stand by" in case of transfusion reaction
- Further Blood Products required? Repeat process. Send Blood Product tag back to TMS
- Document Physician's order for Blood Products includes: - Answers --Patient's first and last name and unique identifier number Medical Record Number (MRN) -Amount and type of blood product -Date, time and rate of infusion (or specify duration) -Any medications to a blood product i.e. irradiation -Special transfusion requirements, i.e. anti-CMV negative -Sequence in which multiple products are to be administered -use of blood warmer or rapid infusion device -any medication orders related to the transfusion
-obtain 1st voided urine specimen and mark on requisition "post-transfusion reaction, routine urinalysis STAT" -return entire transfusion setup, tubing and Blood Product to TMS, ASAP Hyperphosphatemia - Answers -causes renal failure, tetany, muscle twitching, N/V, and tacharrythmias
