[Osborn] chapter 22

Learning Outcomes [Number and Title]

Learning Outcome 1
Compare and contrast the types and uses of catheters for
parenteral administration of solutions and medications.
Learning Outcome 2
Describe the types and uses of parenteral administration
equipment and infusion devices.
Learning Outcome 3
Evaluate the tenets of infusion nursing practice, including
competencies, skill validation, and client assessment.
Learning Outcome 4
Describe components of infusion-specific documentation.
Learning Outcome 5
Discuss the recognition and management of infusion-related
complications, and strategies to prevent complications for the
client receiving infusion therapy.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

1. A clients peripheral intravenous catheter has infiltrated several times during an

8-hour shift. The nurse realizes that the client needs a central venous access device.
Which of the following intravascular devices could a properly trained nurse insert
under the guidelines of the infusion nursing standards of practice?

Select all that apply.

1.
2.
3.
4.
5.

A midline
A peripherally inserted central catheter
An implanted port
A triple-lumen catheter
A tunneled noncuffed catheter

Correct Answer:
1. A midline
2. A peripherally inserted central catheter
Rationale:
A midline. This catheter can be inserted by nurses educated and skilled in the procedure. A
peripherally inserted central catheter. This catheter can be inserted by nurses educated and
skilled in the procedure. An implanted port. An implanted port is used for long-term therapy
and requires an operative procedure for insertion. A triple-lumen catheter. A triple-lumen
catheter is inserted by a physician. A tunneled noncuffed catheter. A tunneled noncuffed
catheter is used for long-term therapy and requires an operative procedure for insertion.
Cognitive level: Applying
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

2. Which of the following nursing diagnoses would explain the purpose of the using
a self-sheathing stylet catheter?
1. Risk for Injury
2. Risk for Fluid-Volume Deficit
3. Risk for Infection
4. Risk for Altered Nutrition

Correct Answer: Risk for Injury

Rationale: Risk for Injury is the nursing diagnosis that explains the purpose of the self-sheathing
catheter. It is engineered with a safety mechanism that causes the needle to become encased in a
protective chamber upon removal from the inserted catheter, thus preventing a needle-stick
injury. A self-sheathing stylet catheter use does not reflect fluid-volume status and is not used to
prevent infection. The use of a self-sheathing stylet catheter is not related to nutritional status.
Cognitive Level: Applying
Nursing Process Planning
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

3. The nurse is preparing a client for discharge with an implanted port. Instructions
for site care would include:

1. No dressings are necessary.

2. Apply a sterile dressing every 2 days.
3. Place a clean bandage daily.
4. Apply a nonadhering dressing weekly.
Correct Answer: No dressings are necessary.
Rationale: No dressings are necessary because the port is completely under the skin. Using a
sterile dressing, nonadhering dressing, or a bandage is incorrect because no dressing is required.
Cognitive Level: Applying
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

4. A client receiving peripheral intravenous therapy is mobile but having difficulty

maneuvering the intravenous infusion pump. The nurse would choose which of the
following add-on devices to allow greater mobility for the client?

1.
2.
3.
4.

An extension set
A stopcock
A filter device
A multiflow adapter

Correct Answer: An extension set

Rationale: An extension set is a device that will add length to the existing administration set and
allow the client to move more freely without having to push the intravenous pump. A stopcock is
used to direct flow of an infusate and would not increase tubing length. A filter device provides
sterility to the infused parenteral medication or solution but does not increase the tubing length.
A multiflow adapter is used for the administration of two or more infusates simultaneously and
does not increase tubing length.
Cognitive Level: Applying
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

5. When the alarm of a clients infusion delivery system sounds, the nurse would
suspect which of the following?

Select all that apply.

1.
2.
3.
4.
5.

Air in the line

Infusion complete
Occlusion of the tubing
Low battery
Infusion infiltration

Correct Answer:
1. Air in the line
2. Infusion complete
3. Occlusion of the tubing
4. Low battery
Rationale:
Air in the line. The infusion pump will detect the presence of air in the fluid pathway of the set.
Infusion complete. The preset volume limit has been reached, which sounds the alarm.
Occlusion of the tubing. Infusion pumps detect disruptions of flow above the catheter and
resistance to flow occurring below the device. Low battery. The alarm will sound if the pump is
requiring more power from being unplugged for client use. Infusion infiltration. The alarm does
not consistently sound for infiltration of an intravenous site; therefore, the intravenous fluid may
continue to infuse into the clients tissue until the infiltration is severe enough to reduce the rate
of delivery.
Cognitive Level: Analyzing
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

6. The nurse is caring for a client with a closed head injury with increased intracranial pressure.
The nurse selects which method to obtain and monitor intracranial pressure readings?
1. An intrathecal catheter
2. An intraspinal catheter
3. An intraosseous catheter
4. A arterial venous shunt
Correct Answer: An intrathecal catheter
Rationale: An intrathecal catheter is used to monitor intracranial pressure as well as drain
cerebral spinal fluid when intracranial pressure is increased. An intraspinal catheter is used for
procedures such as the delivery of anesthesia, diagnostic testing, and infusions. An intraosseous
catheter is inserted into the bones of the long legs or iliac crest and is used to treat thermal
injuries, trauma, cardiac arrest, or other life-threatening illnesses until the traditional vascular
access can be obtained. An arterial venous shunt is used to anastomose venous and arterial
structures often located in the arm for dialysis therapy.
Cognitive Level: Applying
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

7. Prior to initiating infusion therapy for a client, which of the following nursing
diagnoses would the nurse most likely incorporate into the plan of care?

Select all that apply.

1.
2.
3.
4.
5.

Fluid-Volume Deficit
Risk for Infection
Alteration in Comfort
Impaired Gas Exchange
Ineffective Individual Coping

Correct Answers:
1. Fluid-Volume Deficit
2. Risk for Infection
Rationale:
Fluid-Volume Deficit. Infusion therapy will directly reflect the clients fluid volume and
electrolyte status. Risk for Infection. There are inherent risks associated with the invasive nature
of infusion therapy. Knowledge of infection control principles is essential for minimizing and
preventing complications from infection. Alteration in Comfort. There is often minimal shortterm discomfort to the client during insertion of the device for infusion therapy. Impaired Gas
Exchange. This does not reflect the purpose of infusion therapy and reflects the respiratory
status of the client. Ineffective Individual Coping. The clients coping does not reflect the
reason that the client needs infusion therapy.
Cognitive Level: Analyzing
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

8. The nurse would initiate which of the following methods to facilitate drying of the antiseptic
solution applied to the intravenous site?
1. Allow the area to dry itself.
2. Fan the area.
3. Blow on the area.
4. Blot the area.
Correct Answer: Allow the area to dry itself.
Rationale: Allowing the area to dry itself is the infusion therapy standard of practice. Blowing,
fanning, or blotting the prepped area is contraindicated, as this would increase the risk of
infection to the site.
Cognitive Level: Applying
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

9. While flushing a central vascular access device, the nurse meets resistance. The
nurse would:

1.
2.
3.
4.

Check the clamp on the catheter.

Manipulate the catheter.
Apply force to the syringe.
Discontinue the site.

Correct Answer: Check the clamp on the catheter.

Rationale: The nurse would check the clamp on the catheter because the catheter is clamped
when not in use; unclamping the catheter is necessary to initiate flushing of the catheter.
Applying force to the syringe could result in damage to the catheter. Manipulating the catheter
could result in misplacement of the catheter in the vena cava. Discontinuing the site would
require a physicians order.
Cognitive Level: Applying
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

10. The nurse has successfully completed insertion of a peripheral venous catheter.
Documentation following the procedure includes:

Select all that apply.

1. Size, length, and type of catheter.
2. Client complaints of pain during the procedure.
3. Method of securing the catheter.

4. Complications of the procedure.

5. Client participation with the procedure.
Correct Answer:
1. Size, length, and type of catheter.
2. Client complaints of pain during the procedure.
3. Method of securing the catheter.
4. Complications of the procedure.
Rationale:
Size, length, and type of catheter. Documentation of the size, length, and type of catheter will
objectively describe the care rendered during the procedure. This also allows for tracking client
outcomes and monitoring care. Client complaints of pain during the procedure.
Documentation of client complaints of pain during the procedure will objectively describe the
care rendered during the procedure and the clients response to the procedure. This also allows
for tracking client outcomes and monitoring care. Method of securing the catheter.
Documentation of the method of securing the catheter will objectively describe the care rendered
during the procedure. This also allows for tracking client outcomes and monitoring care.
Complications of the procedure. Accurate documentation of complications will objectively
describe the care rendered during the procedure. This also allows for tracking client outcomes
and monitoring care. Client participation with the procedure. Client participation with the
procedure is not considered pertinent information that should be documented when an infusiontherapy-related procedure has been performed.
Cognitive Level: Applying
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

11. The nurse understands that the purpose of accurate documentation of the care
of intravenous access devices is to:

Select all that apply.

1.
2.
3.
4.
5.

Describe the care rendered.

Describe the clients response.
Allow for tracking outcomes.
Prevent injury to the client.
Inform the physician of the procedure.

Correct Answer:
1. Describe the care rendered.
2. Describe the clients response.
3. Allow for tracking outcomes.
Rationale:
Describe the care rendered. Describing the care rendered will objectively reflect the purpose of
accurate documentation. Describe the clients response. Describing the clients response will
objectively reflect the purpose of accurate documentation. Allow for tracking outcomes.
Allowing for tracking of outcomes will objectively reflect the purpose of accurate
documentation. Prevent injury to the client. Preventing injury to the client is incorrect because
this is not the purpose of documentation and does not influence safety of the client. Inform the
health care provider of the procedure. Informing the health care provider of the procedure is
incorrect because the purpose of accurate documentation is to track the care in the clients
medical record.
Cognitive Level: Applying
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

12. The nurse inspects the intravenous catheter after removal. Documentation
would include:

Select all that apply.

1.
2.
3.
4.
5.

Size of catheter.
Length of catheter.
Type of catheter.
Condition of catheter.
Condition of access caps.

Correct Answer:
1. Size of catheter.
2. Length of catheter.
3. Type of catheter.
4. Condition of catheter.
Rationale:
Size of catheter. Documentation of the size of the catheter is necessary after discontinuation of
an intravenous catheter to verify that the catheter did not get sheared or broken when entering the
clients vascular system. Length of catheter. Documentation of the length of the catheter is
necessary after discontinuation of an intravenous to verify that the catheter did not get sheared or
broken when entering the clients vascular system. Type of catheter. Documentation of the type
of catheter is necessary after discontinuation of an intravenous catheter. Condition of catheter.
Documentation of the condition of the catheter is necessary after discontinuation of an
intravenous catheter because this data will verify the intactness of the catheter and verify that the
catheter did not get sheared or broken when entering the clients vascular system. Condition of
access caps. This portion of intravenous catheter insertion does not enter the clients vascular
system.
Cognitive Level: Analyzing
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

13. A client complains of heaviness and swelling in the extremity of the intravenous infusion.
The nurse would first:
1. Discontinue the catheter.
2. Flush the catheter.
3. Document the finding.
4. Notify the physician.
Correct Answer: Discontinue the catheter.
Rationale: The nurse should discontinue the catheter when any sign of phlebitis occurs. Flushing
the catheter will cause further irritation of the surrounding tissue. Documenting the finding is
necessary; however, it is not the initial intervention that should be implemented. Notifying the
health care provider is necessary to obtain treatment of the infiltration, but this is not the initial
intervention that would be performed.
Cognitive Level: Analyzing
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

14. Which of the following nursing diagnoses would the nurse include in the plan of
care for a client with a catheter embolism?

1.
2.
3.
4.

Alteration in Comfort
Impaired Skin Integrity
Fluid-Volume Deficit
Ineffective Coping

Correct Answer: Alteration in Comfort

Rationale: Alteration in Comfort is the correct diagnosis because the client will often experience
chest pain with catheter embolism. Impaired Skin Integrity is incorrect because the catheter has
broken inside the clients vasculature and skin integrity will not be altered. Catheter embolism
does not reflect signs of fluid loss; it will reflect signs of decreased vascular perfusion.
Ineffective Coping is incorrect because the manner in which a client copes does not impact this
life-threatening emergency.
Cognitive Level: Applying
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

15. Following insertion of a peripheral vascular device, the client complains of

shortness of breath, chest pain, and palpitations. The nurse would initially:

1.
2.
3.
4.

Place a tourniquet proximal to the site.

Notify the physician.
Obtain vital signs.
Obtain radiographic studies.

Correct Answer: Place a tourniquet proximal to the site.

Rationale: If a catheter embolism is suspected, immediate interventions need to be initiated; the
nurse would secure a tourniquet on the clients arm to minimize movement of the catheter. Vital
signs would need to be obtained after the tourniquet is placed. The physician would need to be
notified, but this is not the initial intervention Radiographic studies may be indicated to
determine the location of the catheter, but this will be implemented after placement of the
tourniquet, notification of the health care provider, and vital signs are obtained.
Cognitive Level: Analyzing
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.