Which activity related to intravenous therapy can the nurse delegate to assistive personnel

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January 2009 - Volume 32 - Issue 1

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DEPARTMENT: INS Position Paper

The Use of Nursing Assistive Personnel in the Provision of Infusion Therapy

Journal of Infusion Nursing: January 2009 - Volume 32 - Issue 1 - p 21-22

doi: 10.1097/NAN.0b013e3181922334

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Abstract

© Copyright 2009 by the Infusion Nurses Society

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Answer: 

Refer to the Iowa Administrative Code 655, Chapter 6, Section 6.2(5)" c", which states that, "Activities and functions which are beyond the scope of practice of the licensed practical nurse may not be delegated to unlicensed assistive personnel."

When deciding what functions to delegate to unlicensed assistive personnel please refer to the delegation information at this link: Delegation

When delegating it is always necessary to assess the individual patient, the task, and the individual personnel, to ensure that delegation is a safe plan of care for the patient.

Once the decision has been made to delegate a task, there must be adequate education and training, documentation of the competency of the individual, a plan for future evaluation and a written institutional policy for carrying out the procedure.

The RN and LPN maintain accountability for the delegation process, which includes: assessment, the decision to delegate, monitoring and evaluation of the nursing care.

Printed from the Iowa Board of Nursing website on December 14, 2022 at 1:12am.

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Terms in this set (28)

Which statement is true regarding vascular access devices (VADs)?

1. The word "central" applies to the insertion site.
2. Central catheters are long-term devices.
3. Peripheral catheters are used for long-term antibiotic administration.
4. Peripheral catheters are more effective for administration of large volumes of fluids.

2. Central catheters are long-term devices.

Central catheters are long-term devices. The term "central" applies to the location of the catheter tip, not to the insertion site. Peripheral catheters are for short-term use such as for fluid restoration after surgery and short-term administration of antibiotics. Central catheters are mainly useful for administration of large volumes of fluids and for administration of parenteral nutrition. p. 956

Which statement regarding intravenous dressings is true?

1. Dressings should be loosely placed.
2. Transparent dressings are generally avoided.
3. The nursing assistive personnel is involved in intravenous dressing changes.
4. Dressing changes should be done only when the older dressing is compromised

4. Dressing changes should be done only when the older dressing is compromised

Due to the increased risk of catheter displacement, changes are made only if the older dressing is compromised. Loose dressing can displace the vascular access device and increase the risk of bacterial contamination of the venipuncture site. Transparent dressings are preferred over gauze pad dressings. Intravenous dressing changes cannot be delegated to nursing assistive personnel, but can be delegated to licensed practical nurses. p. 987

Which activities can the nurse delegate to nursing assistive personnel (NAP)? Select all that apply.

1. Measuring oral intake and urine output
2. Preparing intravenous (IV) tubing for routine change
3. Reporting an IV container that is low in fluid
4. Changing an IV fluid container
5. Reporting an electronic infusion device alarm

1. Measuring oral intake and urine output
3. Reporting an IV container that is low in fluid
5. Reporting an electronic infusion device alarm

The nurse is able to delegate measuring oral intake and urine output, reporting an IV container that is low in fluid, and reporting an electronic infusion device alarm.The registered nurse cannot delegate working with intravenous (IV) tubing or changing an IV infusion to nursing assistive personnel (NAP). p. 951

What is the normal range of values of phosphate in human blood?

1. 1.5 to 2.5 mEq/L
2. 2.7 to 4.5 mg/dL
3. 3.5 to 5.0 mEq/L
4. 4.5 to 5.3 mg/dL

2. 2.7 to 4.5 mg/dL

The normal range of values of phosphate in human blood is 2.7 to 4.5 mg/dL. The normal value of potassium is 3.5 to 5.0 mEq/L, the normal value of ionized calcium is 4.5 to 5.3 mg/dL, and the normal value of magnesium is 1.5 to 2.5 mEq/L. p. 935

Which physical findings can be seen in a patient with extracellular fluid volume (ECV) deficit? Select all that apply.

1. Edema
2. Thready pulse
3. Crackles in lungs
4. Postural hypotension
5. Dry mucous membranes

2. Thready pulse
4. Postural hypotension
5. Dry mucous membranes

A thready pulse, postural hypotension, and dry mucous membranes are the physical findings of an extracellular fluid volume deficit. Edema in dependent areas and crackles in the lungs are the physical findings of extracellular fluid volume excess. p. 940

The registered nurse is instructing a nursing student about the interventions that must be performed when there is any evidence of complication due to infusion therapy. Which instruction would the nurse follow for a patient with circulatory overload?

1. "Reduce the intravenous (IV) flow."
2. "Elevate the extremity."
3. "Disconnect the IV tubing."
4. "Discontinue the IV infusion."

1. "Reduce the intravenous (IV) flow."

If the nurse suspects circulatory overload in a patient, the immediate nursing intervention is to reduce the IV flow rate and notify the health care provider. The nurse must elevate the extremity when there is any evidence of infiltration near the infusion site; this helps the infiltration to subside. The nurse must disconnect IV tubing and discontinue the IV infusion when there is evidence of infiltration. p. 960

Which clinical criteria of phlebitis should receive a grade of 3?

1. Formation of streak
2. Pain at access site with only erythema
3. Palpable venous cord greater than 2.54 cm
4. Erythema at access site with or without pain

1. Formation of streak

According to the phlebitis scale, the nurse would give a grade of 3 if there is any streak formation or a palpable venous cord. The nurse would give a grade of 2 if there is only erythema. The nurse would grade give a grade of 4 if there is a palpable venous cord greater than 2.54 cm. Erythema at the access site with or without pain is grade 1. p. 961

A nurse is assessing the clinical markers of vascular volume. Which patient may require intravenous (IV) therapy due to extracellular fluid volume deficit?

1. A patient with a full pulse rate
2. A patient with dark yellow urine
3. A patient with increased blood pressure
4. A patient with crackles in the lobe of the lung

2. A patient with dark yellow urine

A dark yellow color indicates concentrated urine that may be caused by a decrease in the extracellular fluid volume; therefore, this patient may require IV therapy. An increase in the pulse rate indicates excess fluid volume. The blood pressure increases with excess extracellular fluid volume. Crackles indicate excess fluid volume p. 968

A patient has extracellular volume deficit due to diarrhea. How should the nurse correct the volume deficit in the patient?

1. Provide caffeinated fluids.
2. Provide low-sodium fluids.
3. Provide fluids that contain lactose.
4. Provide fluids that contain sodium.

4. Provide fluids that contain sodium.

The nurse should use fluids such as an electrolyte replacement, which contains sodium to correct extracellular volume deficit. The sodium in the fluids helps to prevent fluid loss through retention. Caffeinated fluids, low-sodium fluids, and fluids containing lactose are not ideal to correct the extracellular volume deficit of diarrhea. These fluids tend to promote fluid loss and cause dehydration. pp. 940, 955

The primary health care provider orders the nurse to infuse 500 mL normal saline over 4 hours to a patient with a blood pressure of 100/70 mm Hg. What is the flow rate of infusion? Record your answer in mL per hour. _________ mL/hr

125

A patient with a blood pressure of 100/70 mm Hg is hypotensive. Normal saline solution is used to maintain the patient's sodium level. The formula used to calculate the flow rate is the total infusion volume (mL) divided by the hours of infusion. Therefore, 500 mL of normal saline is divided by 4 hours to calculate the infusion rate, which is 125 mL per hour. p. 978

As the nurse is assessing the caseload of patients for the day, which patient would the nurse expect to be at the highest risk of developing dehydration?

1. A 78-year-old patient with dementia
2. A 47-year-old patient with hyperthyroidism
3. A 53-year-old patient with pulmonary embolism
4. A 32-year-old patient with a respiratory infection

1. A 78-year-old patient with dementia

Older patients may become dehydrated because of altered responses to illness related to age. In addition, persons with dementia might not recognize the urge to drink. Patients who are in their 30s, 40s, or 50s with hyperthyroidism, pulmonary embolism, and respiratory infection are not at great risk for dehydration. p. 947

Which complication of intravenous (IV) therapy indicates the need for pressure at the site?

1. Bleeding
2. Phlebitis
3. Infection
4. Fluid overload

1. Bleeding

Bleeding may be a complication of IV therapy; applying pressure at the site can reduce bleeding. Phlebitis may indicate that the infusion should be stopped. The primary health care provider should be notified if symptoms of infection occur. Reduction in the IV flow rate may reduce circulatory overload. p. 960

Which electrolyte influences excitability of nerve and muscle cells and is necessary for muscle contraction?

1. Calcium (Ca 2+)
2. Potassium (K +)
3. Phosphate (PO 4)
4. Magnesium (Mg 2+)

1. Calcium (Ca 2+)

Calcium influences the excitability of nerve and muscle cells and is necessary for muscle contraction. Potassium maintains the resting membrane potential of skeletal, smooth, and cardiac muscle, allowing for normal muscle function. Electrolyte phosphate is necessary for the production of adenosine triphosphate (ATP), the energy source for cellular metabolism. Electrolyte magnesium influences the function of neuromuscular junctions and is a cofactor for numerous enzymes. p. 941

Which method should the nurse adopt to assist in the easy maneuvering of a patient who is on intravenous infusion?

1. Use of stopcocks
2. Disconnection of the tubing
3. Addition of extension tubing
4. Use of catheter stabilization devices

3. Addition of extension tubing

When a patient needs more room to maneuver, extension tubing may be added to the intravenous line. Stopcocks should not be used to connect multiple solutions to a single intravenous site due to the increased risk of contamination. Tubing should not be disconnected for moving a patient. A catheter stabilization device is used to prevent accidental dislodgment of a venous access device. Catheter stabilization devices do not allow easy maneuvering of a patient on infusion. p. 959

Which statement is true regarding the maintenance of the integrity of the intravenous system?

1. The tubing should be removed and reconnected if it is messed up.
2. The injection port should be cleaned using chlorhexidine solution.
3. The maximum number of extension tubes should be used for the easy maneuvering of the patient.
4. Stopcocks may be used to connect more than one solution to a single intravenous site.

2. The injection port should be cleaned using chlorhexidine solution.

A 2% solution of chlorhexidine is the most preferred cleaning agent for injection ports. The tubing should not be disconnected if tangling occurs. Extension tubings can increase the risk of contamination. Thus, their use should be minimized. Using a single intravenous site for multiple solutions with stopcocks can cause contamination. Thus, it should be avoided p. 959

Which ion is an example of an anion?

1. Sodium
2. Calcium
3. Chloride
4. Potassium

3. Chloride

Positively charged ions are called cations. Negatively charged ions are called anions. A chloride (Cl -) ion is an anion. Sodium (Na +), calcium (Ca +), and potassium (K +) are cations. 935

A patient with blood type A is in need of packed red cells on an emergency basis, but none of the donors of this type are available. How can the nurse provide better health care to the patient?

1. Arrange to provide red blood cells of group O.
2. Arrange to provide red cells of group AB.
3. Arrange for an autologous blood transfusion.
4. Wait until the donor of blood type A becomes available.

1. Arrange to provide red blood cells of group O.

The patient requires red blood cells on an emergency basis, and none of the donors of this blood type are available. Therefore, the patient may be managed by transfusion of red cells of blood group O, because this carries minimum risk. Red blood cells of blood group AB should not be given to patients with blood group A, because they cause mismatching. Autologous transfusion takes a few weeks; therefore, it is not suitable on an emergency basis. If the patient did not require blood on an emergency basis, then it would be appropriate to wait until a blood group A donor is found.

Test-Taking Tip: Remember that O is the universal d On Or. p. 962

The nurse uses an antiseptic swab for dressing a patient's intravenous site. What is the rationale for this?

1. To maintain skin integrity
2. To promote adherence of the dressing
3. To prevent irritation from the adhesives
4. To reduce the microbial count at the insertion site

4. To reduce the microbial count at the insertion site

The nurse uses an antiseptic swab to clean the intravenous insertion site and reduce the microbial count at the insertion site. The nurse applies skin protectant solution on the intravenous insertion site to provide a protective coat over the skin to maintain skin integrity. Skin protectant solutions promote the adherence of the dressing, which reduces the irritation caused by the adhesive tapes. p. 988

The primary health care provider tells the nurse to observe the intravenous connections and patency of systems of a patient who is on intravenous fluids. What is the rationale behind this order?

1. Detecting bleeding
2. Ensuring proper fluid administration
3. Maintaining pressure to prevent bleeding
4. Reducing the transmission of microorganisms

2. Ensuring proper fluid administration

Observing intravenous connections and the patency of systems ensures proper fluid administration to the patient. Observing the puncture site detects bleeding. Applying sterile folded gauze helps to prevent bleeding. Discarding the used supplies and performing hand hygiene reduces the risk of infection. p. 986

Which conditions are common in a patient with chronic diarrhea? Select all that apply.

1. Hyperkalemia
2. Hypocalcemia
3. Hypernatremia
4. Hypomagnesemia
5. Hyperphosphatemia

2. Hypocalcemia
3. Hypernatremia
4. Hypomagnesemia

Chronic diarrhea may lead to hypernatremia and result in clinical dehydration. It also leads to hypocalcemia and hypomagnesemia because diarrhea decreases electrolyte absorption. Hypokalemia occurs due to an increase in fluid output, not hyperkalemia. Hyperphosphatemia is uncommon during chronic diarrhea. p. 948

What condition may be suspected in a patient with end-stage renal disease?
1. Hypokalemia
2. Hypercalcemia
3. Hypomagnesemia
4. Hypermagnesemia

4. Hypermagnesemia

Hypermagnesemia is an abnormally high magnesium concentration in the blood; this can be caused by end-stage renal disease. Excessive fluid loss can cause hypokalemia. Malignant neoplasms or increased levels of parathyroid hormone can cause hypercalcemia. Chronic diarrhea can cause hypomagnesemia. p. 941

A patient with vomiting and diarrhea reports lightheadedness while standing from a sitting position. The patient's blood pressure is 90/58 mm Hg. Which intervention would best treat this patient?

1. Administering diuretics
2. Monitoring the patient's 24-hour fluid intake and urine output
3. Limiting the patient's intake of fluids and foods rich in sodium
4. Administering 1000 mL of 0.9% normal saline solution with 10 mEq of potassium chloride

4. Administering 1000 mL of 0.9% normal saline solution with 10 mEq of potassium chloride

A patient with vomiting and diarrhea may experience lightheadedness due to fluid and electrolyte imbalance. The blood pressure may also be altered to 90/58 mm Hg while changing positions, resulting in postural hypotension. Administering 1000 mL of 0.9% normal saline solution with 10 mEq of potassium chloride may accelerate the improvement of the patient's condition. Diuretics such as furosemide and thiazide may lead to hyponatremia and hypokalemia, which may aggravate the patient's condition. Monitoring the patient's 24-hour fluid intake and urine output is important, but it may not directly comfort the patient. Limiting the patient's intake of fluids and foods rich in sodium may worsen the condition. p. 954

Which body fluid is considered an intravascular fluid?

1. Synovial fluid
2. Plasma of the blood
3. Fluid outside the cells
4. Fluid outside the blood vessels

2. Plasma of the blood

Blood plasma is considered an intravascular fluid. Synovial fluid is considered a transcellular fluid. Extracellular fluid is located outside the cells. Interstitial fluid is located outside the blood vessels. p. 935

The skin of a patient taking intravenous fluids appears blanched, cool to the touch, and edematous. Upon touch, the patient reports pain. Which complication does this represent?

1. Phlebitis
2. Extravasation
3. Local infection
4. Circulatory overload

2. Extravasation

Extravasation and infiltration are manifested by painful and blanched skin that is cool to the touch and edematous. Phlebitis is manifested by redness, tenderness, pain, and warmth along the course of the vein starting at the access site. Redness, heat, and swelling indicate a local infection at the catheter entry site. Circulatory overload is manifested by crackles in the dependent parts of the lungs, shortness of breath, and dependent edema. p. 960

A nurse teaches a patient with dehydration about maintaining safe intravenous therapy at home. Which statement made by the patient indicates a need for further learning?

1. "I should perform isometric exercises daily for 30 minutes."
2. "I should cover the injection site with plastic to prevent the site from getting wet during a shower."
3. "I should apply pressure to the injection site with sterile gauze if the catheter falls out."
4. "I should immediately report inflammation and itching at the injection site."

1. "I should perform isometric exercises daily for 30 minutes."

A patient who is undergoing intravenous therapy should not perform isometric exercises because it may lead to bleeding and injury at the injection site. During a shower, the patient should protect the injection site and dressing from getting wet by covering it with plastic. Applying pressure with sterile gauze at the injection site if the catheter falls out helps to reduce bleeding. Inflammation and itching at the injection site may be an indication of infection and phlebitis; the patient should report these manifestations immediately. p. 965

A patient who is undergoing intravenous therapy develops redness, inflammation, and swelling at the catheter site. After further assessment, the nurse finds purulent drainage from the injection site. Which nursing interventions are useful in this situation? Select all that apply.

1. Elevating the extremity
2. Cleaning the skin with alcohol
3. Raising the head of the patient's bed
4. Applying a pressure dressing over the site
5. Inserting a new intravenous line in another extremity

2. Cleaning the skin with alcohol
5. Inserting a new intravenous line in another extremity

Redness, inflammation, swelling at the catheter site coupled with purulent indicate an infection. Cleaning the patient's skin with alcohol helps to maintain asepsis. Inserting a new intravenous line in the other extremity helps to reduce the chance of infection. Elevating the patient's extremity helps to reduce infiltration and extravasation. Raising the head of the patient's bed helps to control extracellular volume excess. The application of a pressure dressing over the injection site helps to reduce bleeding. p. 960

A patient with chronic diarrhea shows Chvostek's sign. What might be the reason behind the patient's condition? Select all that apply.

1. Hypokalemia
2. Hypocalcemia
3. Hyponatremia
4. Hypomagnesemia
5. Hypophosphatemia

2. Hypocalcemia
4. Hypomagnesemia

A patient with chronic diarrhea who has hypocalcemia and hypomagnesemia may show Chvostek's sign which is contraction of facial muscles when the facial nerve is tapped. Hypokalemia, hyponatremia, and hypophosphatemia manifest in other signs and symptoms. p. 942

A primary health care provider orders 2 L of intravenous fluid over 6 hours using gravity-flow tubing and a macrodrip with a drop factor of 10 for a patient who has been vomiting. Calculate the minute flow rate of the infusion in gtt/minute and record your answer as a whole number. _________ gtt/min

56

The minute flow rate is calculated as (mL/hour)(drop factor/60 min) = gtt/min. The flow rate of the intravenous fluid is 2L or 2000 mL for 6 hours, and the drop factor is 10. Therefore, the minute flow rate is: (2000/6)(10/60) = 55.56. This number rounds up to 56 gtt/min. p. 978

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