Question

A nurse is changing the dressing on a central venous access device (CVAD) that has a transparent semipermeable membrane dressing. What is the appropriate frequency for changing this type of dressing?

Answer 1

Correct Answers:

Every 5 to 7 days

Rationale :

🔷 Transparent semipermeable membrane (TSM) dressings are designed to remain sterile and intact for 5–7 days unless soiled or loose, aligning with CDC and INS standards.

🔷 These dressings allow continuous visualization of the CVAD site, reducing the need for frequent manipulation, which lowers the risk of infection.

🔷 Changing the dressing too often disrupts the sterile barrier and increases infection risk by exposing the insertion site unnecessarily.

🔷 TSM dressings are moisture-vapor permeable, maintaining a protective seal for nearly a week without compromising skin integrity.

🔷 Evidence-based practice supports 5–7-day intervals because central lines require minimal disturbance to reduce CLABSI risk.

Every 48 hours

🔷 Changing every 48 hours is recommended for gauze dressings, not transparent dressings.

🔷 This frequency would cause unnecessary site manipulation and increase infection risk.

Every week

🔷 “Every week” is vague and exceeds the maximum safe interval (7 days) allowed for TSM dressings.

🔷 Delaying beyond 7 days increases bacterial colonization risk.

Every 24 hours

🔷 Daily dressing changes are excessive and contradict sterile line-care guidelines.

🔷 Frequent changes raise contamination risk and compromise CVAD stability.

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Answer 2

Correct Answers:

Clamp the IV tubing, remove the old tubing, attach the new tubing, and unclamp

Rationale :

🔶 Clamping prevents air from entering the line, which is essential to prevent air embolism and accidental free-flow of IV fluid.

🔶 Removing the old tubing first maintains control of the line and avoids contamination.

🔶 Attaching new tubing while the line is still clamped ensures proper priming and sterility before infusion resumes.

🔶 Unclamping at the end re-establishes fluid flow safely after the system is secured.

🔶 This sequence supports aseptic technique, patient safety, and correct pressure management.

Incorrect Options

Attach the new tubing, clamp the IV line, and remove the old tubing

🔶 This exposes the tubing end to air before clamping, increasing embolism risk.

🔶 It also risks accidental leakage or contamination.

Unclamp the IV tubing, attach the new tubing, and remove the old tubing

🔶 Leaving the line unclamped during manipulation is unsafe and may cause uncontrolled fluid flow.

🔶 This violates safe IV-changing protocols.

Remove the old tubing, attach the new tubing, and unclamp the IV line

🔶 Removing the old tubing without clamping first risks air entry and leakage.

🔶 Sequence fails to prioritize patient safety.

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Answer 3

Correct Answers

Blank 1 Correct Option: Infection
Blank 2 Correct Option: Monitor for changes at the site and Administer antibiotics
Blank 3 Correct Option: Client’s temperature and Redness and swelling at the site

Rationale :

💠 The presence of redness, tenderness, and swelling extending 2 cm strongly indicates local catheter-site infection.

💠 Ultrasound showing a localized fluid collection supports a diagnosis of infection rather than phlebitis or thrombosis.

💠 The provider ordered vancomycin, confirming suspicion of a bacterial process requiring antibiotic therapy.

💠 Monitoring site changes every 2 hours aligns with early detection of worsening infection or progression to CLABSI.

💠 Assessing temperature is essential because early infection may be afebrile but can progress to systemic involvement.

Phlebitis

💠 Phlebitis presents with streaking along the vein, pain, and warmth, but not usually fluid collection on ultrasound.

💠 Antibiotics are not first-line treatment for uncomplicated phlebitis.

Extravasation

💠 Extravasation involves vesicant leakage into tissue and often causes blistering—not the case here.

💠 Ultrasound would show infiltrated IV fluid rather than infectious collection.

Thrombosis

💠 Thrombosis would cause edema and decreased blood return but not redness spreading or fluid collection.

💠 Pain is usually deeper and less erythematous.

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Answer 4

Correct Answers

Perform hand hygiene before preparing medications [ Anticipated ]
Assess the client for desired effects or adverse effects 1 hour after medication administration [ Contraindicated ]
Verify the client's identity using two Identifiers [ Anticipated ]

Rationale :

💎 Hand hygiene is a foundational infection-control step that prevents contamination before medication preparation.

💎 Using two identifiers (name, DOB) prevents medication administration errors, a core patient-safety practice.

💎 These actions match the “rights of medication administration,” especially the rights of patient, dose, and safety.

💎 They ensure safe preparation steps BEFORE the medication reaches the client.

💎 Monitoring effects after administration is important—but it is NOT a preparation-phase task.

Assess for effects 1 hour after medication administration

💎 This is a “post-administration evaluation,” not a preparation action.

💎 Does not contribute to safe preparation.

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Answer 5

Correct Answers:

125 mL/hr.

Rationale :

◈ IV pump rate formula: Total volume ÷ hours → 1000 mL ÷ 8 hr = 125 mL/hr.

◈ The pump must be exact because incorrect rates can lead to underhydration or fluid overload.

◈ Infusion pumps administer fluids based on hourly precision, making accurate calculation essential for safety.

◈ Normal saline requires controlled infusion to avoid electrolyte shifts or circulatory overload.

◈ This calculation aligns with standard nursing dosage-calculation principles.

100 mL/hr

◈ Would deliver only 800 mL in 8 hours, leading to under-infusion.

◈ Fails to meet provider order.

150 mL/hr

◈ Would deliver 1200 mL, exceeding the ordered volume.

◈ Places patient at risk for fluid overload.

80 mL/hr

◈ Only 640 mL would infuse, under 2/3 of ordered amount.

◈ Could compromise fluid balance.

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Answer 6

Correct Answers:

Tunneled CVADS are surgically implanted under the skin and have a cuff to secure the catheter, reducing infection risk, whereas nontunneled CVADs are percutaneously inserted at the bedside without a cuff and are intended for short-term use.

Rationale :

✨ Tunneled CVADs are placed surgically under the skin, creating a subcutaneous tunnel that lowers infection risk.

✨ They contain a Dacron cuff that promotes tissue ingrowth, increasing stability and reducing bacterial entry.

✨ Tunneled lines are designed for long-term therapy, such as TPN or chemotherapy.

✨ Nontunneled CVADs are inserted percutaneously at the bedside, usually in emergencies or for short-term use.

✨ Correctly distinguishing these devices ensures proper maintenance and prevents CLABSI.

Nontunneled require surgical insertion

✨ Nontunneled lines do not require surgery—they are placed at bedside.

✨ They are intended for short-term, not long-term placement.

Tunneled CVADs do not require sterile dressing changes

✨ All central lines require sterile dressing care.

✨ This option falsely minimizes infection-control steps.

Nontunneled are implanted under the chest wall skin

✨ Nontunneled catheters are not implanted; they enter directly through the skin.

✨ This description incorrectly refers to implanted ports.

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Answer 7

Correct Answers:

Selecting veins that are proximal to previously accessed sites.

Rationale :

🔹 Choosing a vein proximal avoids puncturing damaged or fragile distal veins.

🔹 Previously used sites may have irritation, reducing success of cannulation.

🔹 Proximal sites improve blood flow, lowering risk of infiltration.

🔹 This selection helps preserve distal sites for future IV access.

🔹 It aligns with vein-preservation guidelines, especially important in long-term therapy.

Choosing small veins in the hand for all adults

🔹 Small hand veins have higher risk of infiltration and dislodgement.

🔹 Not appropriate for all patients.

Choosing a vein in an area of flexion

🔹 Flexion areas (wrist, AC) increase kinking and dislodgement.

🔹 Can cause infusion flow issues.

Using veins with smaller diameter than the catheter

🔹 This increases vein trauma.

🔹 Raises risk of phlebitis and infiltration.

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Answer 8

Correct Answers:

Inserts the new device distal to the old IV site.

Rationale :

◆ Placing the new catheter distal protects the vein above from contamination.

◆ It avoids advancing fluid into an area potentially irritated by a previous cannula.

◆ This follows vein-preservation standards.

◆ It reduces risk of phlebitis, infiltration, and infection.

◆ Ensures optimal site integrity for successful cannulation.

Incorrect Answers (2 points each)

Leaves small air bubbles in the infusion tubing

◆ Air bubbles risk air embolism and compromise medication accuracy.

◆ Tubing must always be fully primed.

Wears clean gloves during insertion

◆ IV insertion requires sterile or aseptic technique—not clean gloves only.

◆ Clean gloves do not prevent bloodstream infection.

Shaves the hair on the client’s skin

◆ Shaving increases micro abrasions, raising infection risk.

◆ Hair should be clipped, not shaved.

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Answer 9

Correct Answers:

Inserts the new device distal to the old IV site.

Rationale :

◆ Placing the new catheter distal protects the vein above from contamination.

◆ It avoids advancing fluid into an area potentially irritated by a previous cannula.

◆ This follows vein-preservation standards.

◆ It reduces risk of phlebitis, infiltration, and infection.

◆ Ensures optimal site integrity for successful cannulation.

Leaves small air bubbles in the infusion tubing

◆ Air bubbles risk air embolism and compromise medication accuracy.

◆ Tubing must always be fully primed.

Wears clean gloves during insertion

◆ IV insertion requires sterile or aseptic technique—not clean gloves only.

◆ Clean gloves do not prevent bloodstream infection.

Shaves the hair on the client’s skin

◆ Shaving increases micro abrasions, raising infection risk.

◆ Hair should be clipped, not shaved.

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Answer 10

Correct Answers:

22-gauge catheter

Rationale :

🌟 A 22-gauge is appropriate for pediatrics because it fits small, fragile veins.

🌟 It allows effective delivery of antibiotics without excessive vein trauma.

🌟 Larger gauges increase risk of infiltration and pain.

🌟 This size supports safe flow rates while maintaining vein integrity.

🌟 It matches pediatric IV therapy recommendations.

Incorrect Answers (2 points each)

14-gauge catheter

🌟 Too large; causes severe vein trauma.

🌟 Used for rapid resuscitation, not routine antibiotics.

20-gauge catheter

🌟 Still large for many 4-year-old veins.

🌟 Increases complication risk.

18-gauge catheter

🌟 Far too large; used for surgery/trauma adults.

🌟 Would cause unnecessary pain.

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Potential Action	Anticipated	Contraindicated
Perform hand hygiene before preparing medications
Assess the client for desired effects or adverse effects 1 hour after medication administration
Verify the client's identity using two Identifiers

QLexNursing

1 :
A nurse is changing the dressing on a central venous access device (CVAD) that has a transparent semipermeable membrane dressing. What is the appropriate frequency for changing this type of dressing?

2 :
A nurse needs to change the IV tubing for a client receiving peripheral IV therapy. What is the correct procedure for this task?

3 :
Client admitted with central venous catheter.

Correct Answers

4 :
A nurse is caring for a client who has been admitted for a routine observation.

Correct Answers

5 :
A nurse is setting the infusion rate for an IV fluid order of 1000 mL of normal saline over 8 hours. What should the infusion pump rate be ser to

7 :
What is the primary consideration for selecting a peripheral vein for IV insertion?

8 :
A nurse is assisting with supervising a newly licensed nurse replace a short-peripheral IV device for a client. Which of the following actions by the new nurse indicates an understanding of the procedure?

9 :
A nurse is assisting with supervising a newly licensed nurse replace a short-peripheral IV device for a client. Which of the following actions by the new nurse indicates an understanding of the procedure?

10 :
A nurse is preparing to insert a peripheral IV catheter in a 4-year-old pediatric client who requires intravenous antibiotics. Considering the patient's age and vein fragility, which gauge size catheter should the nurse select to ensure effective therapy and minimize vein trauma?

QLexNursing

1 : A nurse is changing the dressing on a central venous access device (CVAD) that has a transparent semipermeable membrane dressing. What is the appropriate frequency for changing this type of dressing?

2 : A nurse needs to change the IV tubing for a client receiving peripheral IV therapy. What is the correct procedure for this task?

3 : Client admitted with central venous catheter.

Correct Answers

4 : A nurse is caring for a client who has been admitted for a routine observation.

Correct Answers

5 : A nurse is setting the infusion rate for an IV fluid order of 1000 mL of normal saline over 8 hours. What should the infusion pump rate be ser to

7 : What is the primary consideration for selecting a peripheral vein for IV insertion?

8 : A nurse is assisting with supervising a newly licensed nurse replace a short-peripheral IV device for a client. Which of the following actions by the new nurse indicates an understanding of the procedure?

9 : A nurse is assisting with supervising a newly licensed nurse replace a short-peripheral IV device for a client. Which of the following actions by the new nurse indicates an understanding of the procedure?

10 : A nurse is preparing to insert a peripheral IV catheter in a 4-year-old pediatric client who requires intravenous antibiotics. Considering the patient's age and vein fragility, which gauge size catheter should the nurse select to ensure effective therapy and minimize vein trauma?

1 :
A nurse is changing the dressing on a central venous access device (CVAD) that has a transparent semipermeable membrane dressing. What is the appropriate frequency for changing this type of dressing?

2 :
A nurse needs to change the IV tubing for a client receiving peripheral IV therapy. What is the correct procedure for this task?

3 :
Client admitted with central venous catheter.

4 :
A nurse is caring for a client who has been admitted for a routine observation.

5 :
A nurse is setting the infusion rate for an IV fluid order of 1000 mL of normal saline over 8 hours. What should the infusion pump rate be ser to

7 :
What is the primary consideration for selecting a peripheral vein for IV insertion?

8 :
A nurse is assisting with supervising a newly licensed nurse replace a short-peripheral IV device for a client. Which of the following actions by the new nurse indicates an understanding of the procedure?

9 :
A nurse is assisting with supervising a newly licensed nurse replace a short-peripheral IV device for a client. Which of the following actions by the new nurse indicates an understanding of the procedure?

10 :
A nurse is preparing to insert a peripheral IV catheter in a 4-year-old pediatric client who requires intravenous antibiotics. Considering the patient's age and vein fragility, which gauge size catheter should the nurse select to ensure effective therapy and minimize vein trauma?