CRNI Infusion Therapy Documentation and Standards Practice Test Flashcards

Which professional organization publishes the Infusion Nursing Standards of Practice that serve as the primary reference for infusion nurses in the United States?

Answer: Infusion Nurses Society (INS)

The Infusion Nurses Society (INS) publishes the Infusion Nursing Standards of Practice, which is the authoritative reference for infusion therapy practice in the US.

A home infusion patient's electronic health record shows the infusion pump delivered 200 mL more than the ordered volume. What is the nurse's first documentation priority?

Answer: Document the discrepancy, patient assessment findings, provider notification, and actions taken, then complete an incident report

A volume discrepancy is a medication error requiring immediate patient assessment, provider notification, incident reporting, and thorough documentation of the sequence of events.

According to INS standards, what must be documented when a PICC line tip position is confirmed by chest radiograph?

Answer: The date of X-ray, tip location as reported by radiologist, provider notification of results, and any actions taken

INS requires nursing documentation to include the date and result of tip verification imaging, who was notified, and any subsequent actions to establish safe line use.

A patient on long-term parenteral nutrition develops signs of air embolism. Which documentation sequence is correct?

Answer: Immediately document the time symptoms were identified, patient position changes, oxygen applied, provider notified, and patient response as events unfold

Contemporaneous documentation of the time of symptom recognition, emergency interventions, and patient response creates an accurate record and is essential for legal and quality review.

Under HIPAA, which practice is appropriate when faxing infusion therapy orders to a home health agency?

Answer: Use a HIPAA-compliant fax cover sheet with a confidentiality notice and verify the receiving fax number before transmitting

HIPAA requires reasonable safeguards when transmitting PHI, including a confidentiality notice on fax cover sheets and verification of the correct recipient number before sending.

A nurse documents 'patient tolerated infusion well' without vital signs or site assessment findings. This type of documentation is considered:

Answer: Inadequate, because it lacks objective data required by INS standards and organizational policy

INS standards require objective assessment data including site condition and patient response; subjective summaries without clinical findings do not meet professional documentation standards.

Which INS-recommended element differentiates documentation of a vesicant extravasation from routine IV site documentation?

Answer: Extravasation documentation must include site photograph (when policy allows), estimated volume extravasated, extent of tissue involvement, all interventions, provider notification, and follow-up plan

Vesicant extravasation documentation requires additional elements beyond standard site documentation because of the potential for serious tissue injury and medical-legal significance.