f.Apply label if medication was added to the
container, if not done by the pharmacy.
3.Following preparation of the IV solution and
tubing, which of the following actions would
be performed by the nurse when selecting a
site and palpating a vein to start an IV
infusion? (Select all that apply.)
a.Place the patient in a high Fowler’s position
in bed.
b.Select an appropriate site and palpate acces-
sible veins.
c.Apply a tourniquet 2 to 3 inches above the
venipuncture site to obstruct venous flow
and distend the vein.
d.Direct the ends of the tourniquet away
from the site and check that the radial
pulse is still present.
e.Ask the patient to keep a tightly closed fist
while observing and palpating for a suitable
vein.
f.If a vein cannot be felt, release the tourniquet
and have the patient lower the arm below
the level of the heart to fill the veins.
4.Which of the following are recommended
actions for a nurse to perform after selecting a
site and palpating accessible veins in order to
start an IV infusion? (Select all that apply.)
a.Clean the entry site with saline, followed
by an alcohol swab according to agency
policy.
b.Place the dominant hand about 4 inches
below the entry site to hold the skin taut
against the vein.
c.Enter the skin gently with the catheter held
by the hub in the nondominant hand,
bevel side down, at a 10- to 30-degree
angle.
d.Advance the needle or catheter into the
vein. A sensation of “give” can be felt when
the needle enters the vein.
e.When blood returns through the lumen of
the needle or the flashback chamber of the
catheter, advance either device^1 ⁄ 8 to^1 ⁄ 4 inch
farther into the vein.
f.Release the tourniquet and quickly remove
the protective cap from the IV tubing and
attach the tubing to the catheter or needle.5.Which of the following are signs of complica-
tions and their probable causes that may
occur when administering an IV solution to a
patient? (Select all that apply.)
a.Swelling, pain, coolness, or pallor at the
insertion site may indicate infiltration of
the IV.
b.Redness, swelling, heat, and pain at the site
may indicate phlebitis.
c.Local or systemic manifestations may indi-
cate an infection is present at the site.
d.A pounding headache, fainting, rapid pulse
rate, increased blood pressure, chills, back
pains, and dyspnea occur when an air
embolus is present.
e.Bleeding at the site when the IV is discontin-
ued indicates an infection is present.
f.Engorged neck veins, increased blood pres-
sure, and dyspnea occur when a thrombus
is present.
6.Which of the following statements accurately
describe the function or regulation of sodium
in the human body? (Select all that apply.)
a.Sodium does not influence ICF volume.
b.Sodium is the primary regulator of ECF
volume.
c.The daily value of sodium cited on nutrition
facts labels is 1,200 mg.
d.Sodium is normally maintained in the
body within a relatively narrow range, and
deviations quickly result in serious health
problems.
e.The normal extracellular concentration of
sodium is 85 to 95 mEq/L.
f.Sodium participates in the generation and
transmission of nerve impulses.
7.Which of the following statements accurately
describe the function or regulation of
potassium in the body? (Select all that apply.)
a.Potassium is the major cation of ICF and
works reciprocally with sodium.
b.Potassium is the chief regulator of cellular
enzyme activity and cellular water content.
c.Potassium is needed for vitamin B 12 absorp-
tion and for its use by body cells.
d.Potassium determines the thickness and
strength of cell membranes.274 UNIT VII PROMOTING HEALTHY PHYSIOLOGIC RESPONSES
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:LWBK696-C40_p272-282.qxd 9/3/10 12:35 PM Page 274 Aptara Inc