CRNI Infusion Therapy Documentation and Standards Practice Test 2 — Questions and Answers
Question 1: What is the standard documentation requirement for blood product administration?
- Recording the blood type only
- Two-nurse verification of patient identity and blood product compatibility, vital signs at baseline, 15 minutes, and completion, and continuous observation documentation (Correct answer)
- Only the volume transfused
- Date and time only
Correct answer: Two-nurse verification of patient identity and blood product compatibility, vital signs at baseline, 15 minutes, and completion, and continuous observation documentation
Blood product documentation requires recording the two-nurse independent verification at the bedside (patient identity matched against blood bank label), vital signs at baseline, 15 minutes, hourly, and at completion, start and stop times, total volume transfused, any reactions observed, and the patient's tolerance. The blood product identification number must also be documented.
Question 2: Which documentation standard applies to the use of restraints in patients who repeatedly remove IV access devices?
- No documentation needed
- Physician order, patient assessment, alternatives tried, least restrictive device used, regular reassessment intervals, and removal criteria (Correct answer)
- Only the nurse's note that restraints were applied
- Only the type of restraint used
Correct answer: Physician order, patient assessment, alternatives tried, least restrictive device used, regular reassessment intervals, and removal criteria
Restraint use requires comprehensive documentation including a physician order with clinical justification, assessment of patient condition, documentation of less restrictive alternatives attempted first, the specific restraint type used, regular reassessment at defined intervals (typically every 1-2 hours), neurovascular checks, and criteria for discontinuation.
Question 3: What is the standard for documenting patient education related to infusion therapy?
- No documentation needed for education
- Content taught, method of instruction, patient's understanding (demonstrated competency), and language/cultural accommodations made (Correct answer)
- Only that education was provided
- Only if the patient asks questions
Correct answer: Content taught, method of instruction, patient's understanding (demonstrated competency), and language/cultural accommodations made
Patient education documentation should include the specific content taught (therapy purpose, expected duration, potential complications, self-monitoring instructions), the teaching method used (verbal, written, demonstration), the patient's demonstration of understanding (return demonstration, teach-back), and any accommodations made for language, literacy, or cultural needs.
Question 4: According to INS standards, how should vascular access device site assessments be documented?
- Only when problems are identified
- At every site assessment using a standardized scale (VIP for phlebitis, infiltration scale) with objective findings documented (Correct answer)
- Weekly summary only
- Only at shift change
Correct answer: At every site assessment using a standardized scale (VIP for phlebitis, infiltration scale) with objective findings documented
INS standards require site assessment documentation at every assessment interval using standardized scales. The VIP scale should be used for phlebitis assessment and the INS infiltration scale for infiltration. Documentation should include objective findings (erythema extent, edema measurement, temperature, drainage), actions taken, and patient symptoms. This creates a trackable trend over time.
Question 5: What documentation is required when discontinuing a central venous catheter?
- Date of removal only
- Date, time, reason for removal, catheter tip integrity verification, site assessment, dressing applied, patient position during removal, and any complications (Correct answer)
- Only the nurse's signature
- No documentation is required for removal
Correct answer: Date, time, reason for removal, catheter tip integrity verification, site assessment, dressing applied, patient position during removal, and any complications
CVC removal documentation must include the date and time, reason for discontinuation, patient position during removal (Valsalva, Trendelenburg), description of the catheter tip (intact, complete length), exit site assessment, type of dressing applied, patient tolerance, whether the catheter tip was sent for culture, and any complications encountered during removal.
Question 6: Which standard governs the labeling of IV infusion tubing and containers?
- No labeling standard exists
- All tubing must be labeled with medication name, date and time of tubing change, and initials; containers must have patient identification and solution information (Correct answer)
- Only the date is required
- Labeling is optional
Correct answer: All tubing must be labeled with medication name, date and time of tubing change, and initials; containers must have patient identification and solution information
Standard practice requires that IV tubing be labeled with the date and time of initiation, medication name, flow rate, and the nurse's identification. Solution containers must have the patient's name, medication name and dose, rate, time of preparation, and expiration. Proper labeling prevents medication errors, ensures timely tubing changes, and facilitates line identification.
CRNI Infusion Therapy Documentation and Standards Practice Test 2
What is the standard documentation requirement for blood product administration?