CRNI CRNI Infusion Therapy Documentation and Standards Practice Test 4 — Questions and Answers
Question 1: When documenting a peripheral IV insertion, which element is MOST critical to include per INS standards?
- Patient's insurance information
- Catheter gauge, length, and insertion site with anatomical landmark (Correct answer)
- Name of the physician who ordered the IV
- Time the order was received by pharmacy
Correct answer: Catheter gauge, length, and insertion site with anatomical landmark
INS standards require documentation of catheter gauge, length, insertion site with anatomical landmark, number of attempts, and patient response.
Question 2: A nurse is documenting a central venous catheter (CVC) dressing change. Which finding requires an incident report in addition to the medical record entry?
- Transparent semipermeable membrane dressing intact with no signs of infection
- Mild erythema at insertion site that was present at last assessment
- Catheter tip migrated outside the SVC noted on chest X-ray (Correct answer)
- Patient verbalized discomfort during dressing change
Correct answer: Catheter tip migrated outside the SVC noted on chest X-ray
Catheter tip migration outside the SVC is a safety event requiring both medical record documentation and an incident/occurrence report.
Question 3: According to The Joint Commission standards, how should an infusion-related verbal order be documented?
- The nurse may paraphrase the order for brevity
- Read back the order to the prescriber and document it as a verbal order with the prescriber's name (Correct answer)
- Document it only after the prescriber signs it within 48 hours
- Verbal orders for infusions are not permitted under TJC standards
Correct answer: Read back the order to the prescriber and document it as a verbal order with the prescriber's name
TJC requires a read-back verification of verbal orders, which must be documented with the prescriber's name and countersigned within the facility-defined timeframe.
Question 4: What is the recommended documentation timeframe for reassessing a peripheral IV site per INS 2021 standards?
- Every 4 hours for adults
- At least every 4 hours, or per organizational policy, with every nursing assessment (Correct answer)
- Once per shift regardless of patient condition
- Only when the patient reports pain
Correct answer: At least every 4 hours, or per organizational policy, with every nursing assessment
INS 2021 recommends assessing and documenting peripheral IV site condition at least every 4 hours and with every nursing assessment, or per organizational policy.
Question 5: A patient receives a blood transfusion. Which documentation set is required to meet AABB and INS standards?
- Product type and volume only
- Pre- and post-transfusion vital signs, product type, unit number, blood type, volume infused, start/stop times, and patient response (Correct answer)
- Physician order and nursing signature
- Product number and start time only
Correct answer: Pre- and post-transfusion vital signs, product type, unit number, blood type, volume infused, start/stop times, and patient response
AABB and INS standards require comprehensive transfusion documentation including identifiers, vital signs, volume, timing, and patient response to ensure traceability and safety.
Question 6: Which action best demonstrates compliance with medication reconciliation standards for home infusion therapy at discharge?
- Providing a verbal summary of the infusion regimen to the patient
- Documenting a written reconciled medication list that includes the home infusion drug, dose, rate, and frequency signed by the provider (Correct answer)
- Faxing the pharmacy a copy of the discharge summary
- Noting the infusion therapy in the nursing discharge note only
Correct answer: Documenting a written reconciled medication list that includes the home infusion drug, dose, rate, and frequency signed by the provider
A provider-signed written reconciled medication list that includes all infusion therapy details is required to meet CMS and accreditation medication reconciliation standards at discharge.
Question 7: When documenting a suspected catheter-associated bloodstream infection (CLABSI), what is the nurse's primary documentation responsibility?
- Remove the catheter and discard it before documenting
- Document objective clinical signs, actions taken, cultures obtained, provider notification, and time sequence of events (Correct answer)
- Wait for culture results before documenting any infection-related notes
- Document only if the infection is confirmed by the infection control team
Correct answer: Document objective clinical signs, actions taken, cultures obtained, provider notification, and time sequence of events
Complete, timely documentation of signs, interventions, cultures, and provider notification creates an accurate clinical record and supports CLABSI surveillance and reporting.
CRNI CRNI Infusion Therapy Documentation and Standards Practice Test 4
When documenting a peripheral IV insertion, which element is MOST critical to include per INS standards?