Accurate IV documentation should include:

Only the start time of the infusion

Catheter gauge, site, solution, and client response

The provider's name only

The client's diagnosis only

Answer and Explanation

The Correct Answer is B

Rationale:

A. Only the start time of the infusion is incorrect because documenting only the start time fails to provide critical information about the IV therapy. Comprehensive documentation ensures patient safety, legal protection, and continuity of care.

B. Catheter gauge, site, solution, and client response is correct because accurate IV documentation should include all relevant details: the size and type of catheter, the insertion site, the IV fluid or medication being administered, and the patient’s response to the therapy (e.g., adverse reactions, tolerance, or discomfort). This ensures effective monitoring, early detection of complications, and clear communication with the healthcare team.

C. The provider's name only is incorrect because the provider’s name alone does not document the administration or safety of IV therapy. While noting the prescriber is part of the record, it is insufficient for comprehensive documentation.

D. The client's diagnosis only is incorrect because the patient’s diagnosis does not reflect the actual IV therapy, catheter details, or patient response. Documentation must focus on what was done, how it was done, and how the patient tolerated it.

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Correct Answer is A

Explanation

Rationale:
A. Carefully remove the gloves and follow with hand hygiene is correct because gloves are considered personal protective equipment (PPE) that protect the nurse from exposure to bloodborne pathogens. Once contaminated, gloves should be removed properly to prevent further contamination, followed immediately by hand hygiene to ensure any residual microorganisms on the skin are removed. This follows standard infection control protocols.

B. Prepare an incident report is incorrect because a blood spill on gloves does not require an incident report if no exposure occurred and proper procedures were followed. Incident reports are reserved for needlestick injuries or other breaches in standard precautions that pose risk of infection.

C. Ask the client to undergo a blood test is incorrect because the client has no documented infection, and a blood test is not warranted. Testing the client would be unnecessary, invasive, and not indicated by standard precautions.

D. Wash the gloved hands and then throw the gloves away is incorrect because washing gloves is ineffective in removing pathogens and does not replace proper hand hygiene. Contaminated gloves must be discarded and hands washed thoroughly after removal.

A. Change IV tubing every 24 hours B. Flush the IV catheter frequently C. Perform hand hygiene before and after IV care D. Wear gloves during insertion

Correct Answer is C

Explanation

Rationale:

A. Change IV tubing every 24 hours is incorrect because current evidence-based guidelines recommend changing IV tubing according to type of fluid and facility policy, often every 72 hours for continuous infusions or every 24 hours for blood products or TPN, not automatically every 24 hours. While tubing changes help reduce infection risk, hand hygiene is more fundamental.

B. Flush the IV catheter frequently is incorrect because flushing helps maintain line patency and prevents medication interactions, but it does not directly prevent bloodstream infections unless done as part of aseptic technique.

C. Perform hand hygiene before and after IV care is correct because hand hygiene is the single most effective method to prevent catheter-related bloodstream infections (CRBSIs). Contaminated hands are a primary source of pathogens introduced during catheter insertion, medication administration, or line manipulation. Proper hand hygiene reduces microbial transmission and protects both patient and healthcare provider.

D. Wear gloves during insertion is incorrect because while sterile gloves are required during insertion, gloves alone cannot prevent infection if hand hygiene is neglected. Gloves are a barrier, but contamination can still occur if hands are not clean before gloving or if aseptic technique is broken.

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Accurate IV documentation should include:

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Naxlex Comprehensive Predictor Exams

A nurse is inserting an intravenous catheter for a client which results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

Which action is most important to prevent catheter-related bloodstream infection?

Correct Answer is C

Explanation

When discontinuing a peripheral IV catheter, the LVN should:

When flushing a peripheral IV catheter, the LVN should

A client receiving IV fluids suddenly develops dyspnea and crackles. The LVN should suspect:

During IV medication administration, which assessment is most important to perform repeatedly?

Before administering an IV medication, the LVN's priority action is to:

A client has IV infiltration. What is the priority action?

Which assessment finding indicates a possible adverse IV medication reaction?

A nurse is collecting data from a client who has an intravenous (IV) catheter in her left forearm. The nurse should identify that which of the following findings indicates the client has phlebitis?