Share This Link

Monitor client response to IV medications is incorrect because monitoring patient response is well within the LVN scope of practice. This includes observing for therapeutic effects and adverse reactions and reporting findings to the registered nurse or provider.

Stop an infusion for a suspected adverse reaction is incorrect because LVNs are permitted to stop an infusion if the patient is experiencing a suspected adverse reaction. This action prevents further harm and aligns with patient safety protocols.

Hang a secondary IV medication (piggyback) as ordered is incorrect because in many states, including Texas, LVNs can hang secondary IV medications if it is per facility policy and within their training and scope. This does not usually require independent judgment beyond following the order.

14-16 gauge is incorrect because these are large-bore catheters typically used for trauma, surgery, or rapid fluid resuscitation. Using such large catheters for routine therapy can be unnecessary and more painful for the patient.

25 gauge is incorrect because this is a very small catheter, usually reserved for pediatric or geriatric patients with fragile veins, or for IV access when minimal flow is required. It is not suitable for routine adult IV therapy due to slow flow rates.

22-24 gauge is incorrect because while smaller gauges are sometimes used in adults with difficult veins or for short-term therapy, the 18-20 gauge remains the standard for routine adult IV therapy, balancing flow and patient comfort.

Fever and chills is incorrect because these are systemic manifestations of infection, which usually occur later after bacteria have entered the bloodstream (catheter-related bloodstream infection). Relying on fever and chills alone delays early intervention, increasing the risk of serious complications.

Hypotension is incorrect because it is a late, severe systemic sign, often seen in sepsis or septic shock. It does not indicate a localized IV site infection. Waiting for hypotension would be dangerously late in intervention.

Pulmonary crackles is incorrect because crackles indicate fluid accumulation in the lungs, often related to heart failure or fluid overload, not infection at an IV site. This is irrelevant to early IV site infection.

IV pump alarm sounds is incorrect because while an alarm requires attention, it is not automatically an emergency. Many alarms are due to minor issues like air in the line, temporary occlusion, or the need to refill the bag. The nurse should troubleshoot promptly, but it does not take priority over a patient-reported adverse symptom.

Infusion is slow is incorrect because a slow infusion can affect the timing of medication delivery, but it is not an immediate threat to patient safety unless it persists and prevents critical drug administration. The nurse can correct the rate after assessing the patient.

Slight redness at the site is incorrect because mild redness is a sign of early irritation or phlebitis and should be monitored, but it does not require immediate action unless it worsens or is accompanied by pain, swelling, or systemic symptoms.

Administer IV push medications independently is incorrect because in Texas, LVNs cannot independently give IV push (bolus) medications. This is considered a high-risk skill requiring RN judgment. LVNs may administer IV push only if explicitly allowed by facility policy, training, and competency validation.

Prescribe IV fluids is incorrect because prescribing medications or fluids is outside the LVN scope of practice. LVNs follow orders from a licensed provider; prescribing is reserved for physicians, nurse practitioners, or physician assistants.

Insert a central venous catheter is incorrect because central line insertion is a complex, high-risk procedure reserved for RNs with specialized training, nurse practitioners, or physicians. LVNs do not perform central line insertions.

Reassure the client this is expected is incorrect because dizziness and nausea during IV administration are not automatically normal. Assuming it’s expected ignores potential adverse reactions and may delay appropriate intervention.

Administer an antiemetic is incorrect because giving medication before assessing the patient’s status or determining the cause of symptoms may be unsafe. An antiemetic does not address the potential underlying problem, such as hypotension, allergic reaction, or rapid infusion.

Document findings is incorrect because while documentation is important, it should never be the first action when a client is showing potential adverse effects. Immediate assessment and intervention take priority.

Increase medication absorption is incorrect because a saline lock does not affect how medications are absorbed. IV medications are delivered directly into the bloodstream, and absorption is immediate regardless of a saline lock.

Provide continuous IV fluids is incorrect because a saline lock is specifically not used for continuous fluid administration. If continuous fluids are needed, a standard IV setup with an infusion pump or gravity system is used instead.

Prevent phlebitis is incorrect because while proper IV care can reduce phlebitis, the primary purpose of a saline lock is access, not preventing vein inflammation. Phlebitis prevention depends on site selection, catheter size, and monitoring, not the presence of a saline lock itself.

To ensure sterility is incorrect because sterility is maintained by aseptic technique, not by priming the tubing. Priming does not sterilize the line; the tubing and IV fluids must already be sterile.

To improve flow rate is incorrect because priming the tubing does not directly speed up the infusion. Flow rate is controlled by the IV pump, roller clamp, or pressure settings, not by priming.

To warm the fluid is incorrect because priming does not warm IV fluids. Fluid warming is done separately using IV fluid warmers if clinically indicated, especially for rapid infusion of large volumes.

The provider’s name only is incorrect because while it is important to note the prescribing provider for accountability, it does not provide information about the IV procedure, the solution being infused, or the client’s response. Without this information, safe monitoring and evaluation of treatment are not possible.

Only the start time of the infusion is incorrect because documenting only the start time fails to include the details necessary to monitor the patient and IV site, track infusion progress, or detect complications. Start time alone is insufficient for safe, legal, and effective care.

The client’s diagnosis only is incorrect because the diagnosis does not provide information about the IV therapy itself. While the diagnosis might guide the reason for IV therapy, documentation must focus on procedural details, patient response, and safety monitoring.

The client has cyanosis of the nail beds and pain along the vein is more indicative of impaired circulation or venous obstruction rather than phlebitis. Cyanosis signals decreased oxygenation, not inflammation of the vein.

The client's skin is cool to the touch around the insertion site suggests infiltration, where IV fluid is leaking into the surrounding tissue, rather than phlebitis. In phlebitis, the area is typically warm.

Purulent drainage is noted at the catheter insertion site indicates a local infection or catheter-related bloodstream infection, not phlebitis. While infection can accompany phlebitis, the hallmark signs are redness, tenderness, and vein hardness rather than pus.