CRNI Infusion Therapy Documentation and Standards Practice Test Flashcards

What is the standard documentation requirement for blood product administration?

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.

Which documentation standard applies to the use of restraints in patients who repeatedly remove IV access devices?

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.

What is the standard for documenting patient education related to infusion therapy?

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.

According to INS standards, how should vascular access device site assessments be documented?

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.

What documentation is required when discontinuing a central venous catheter?

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.

Which standard governs the labeling of IV infusion tubing and containers?

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.