Medical Surgical Fluid & Electrolyte Basics #3

Question

The nurse is caring for a client receiving IV fluids. When monitoring the IV bag, she notices the drip chamber has ceased. Which action by the nurse is contraindicated in restoring flow?

Answers

  1. Check for kinks in the tube.
    • Rationale:

      This answer is not correct because tubing should be checked for kinks when flow is interrupted. A kink in the tubing can occur if the client is laying on the tube or the tube is wrapped around the IV pole for instance.

  2. Make sure the roller flow control clamp is open.
    • Rationale:

      This answer is not correct because if the roller clamp is closed, flow of the IV fluid will cease. If the roller clamp is rolled one way, it squeezes the tubing tightly, preventing flow. If it is rolled the other way, it loosens its pinch and opens the tube allowing for more fluid to flow through.

  3. Reposition client's hand or arm.
    • Rationale:

      This answer is not correct because if the IV catheter is placed in an area of flexion, flow may be interrupted when the client moves around. Sometimes it may be necessary to replace the cannula in case the cannula punctures the vein and leaks into surrounding tissue.

  4. Hand flush the IV catheter.
    • Rationale:

      This answer is correct because if resistance is felt during flushing and force is applied, this may result in extravasation. Push the plunger slowly so the solution goes into the catheter. Make sure the syringe is twisted securely into the injection cap and the tubing above the cap is unclamped. If you still feel resistance, stop and call your health care team.

Overview

A drip chamber is part of the intravenous tubing into which fluid falls where the rate of flow can be monitored. When the dripping has stopped, flow has been interrupted. Reasons for this include kinks in the tubing, the clamp is closed, or the client has their arm bent at the catheter site.

Explanation

Learning Outcomes

A drip chamber is part of the intravenous tubing into which fluid falls where the rate of flow can be monitored. When the dripping has stopped, flow has been interrupted. Reasons for this include kinks in the tubing, the clamp is closed, or the client has their arm bent at the catheter site.A kink in the tubing can occur if the client is laying on the tube or the tube is wrapped around the IV pole, for instance, if the roller clamp is closed, flow of the IV fluid will cease. If the IV catheter is placed in an area of flexion, flow may be interrupted when the client moves around. Never attempt to flush the IV in an attempt to restore flow. If resistance is felt during flushing and force is applied, this may result in extravasation.

Test Taking Tip

Read each question in its entirety before looking at the answer options. Use the process of elimination for problem questions. Answer the questions you recognize first.

Video Rationale