IV IV Site Care & Maintenance 1 — Questions and Answers
Question 1: According to INS standards, how often should transparent semipermeable membrane (TSM) dressings be changed on peripheral IV sites?
- Every 24 hours
- Every 48 hours
- Every 5–7 days or when integrity is compromised (Correct answer)
- Every 72 hours
Correct answer: Every 5–7 days or when integrity is compromised
INS standards recommend changing TSM dressings on peripheral IVs every 5–7 days or immediately when the dressing is soiled, loosened, or no longer intact.
Question 2: What is the maximum recommended dwell time for a peripheral IV catheter in adults per current INS guidelines?
- 48 hours
- 72 hours
- 96 hours
- No set time limit — replace only on clinical indication (Correct answer)
Correct answer: No set time limit — replace only on clinical indication
Current INS standards recommend removing peripheral IV catheters based on clinical indication rather than a routine scheduled replacement interval.
Question 3: Which antiseptic solution is preferred for skin antisepsis prior to peripheral IV insertion in adults?
- Povidone-iodine 10%
- Isopropyl alcohol 70% alone
- Chlorhexidine gluconate >0.5% in alcohol (Correct answer)
- Normal saline
Correct answer: Chlorhexidine gluconate >0.5% in alcohol
Chlorhexidine gluconate (CHG) >0.5% combined with alcohol is the preferred antiseptic for IV insertion site preparation due to its broad-spectrum efficacy and residual activity.
Question 4: A nurse assesses a peripheral IV site and notes the Phlebitis Scale score as 2. What finding corresponds to this score?
- No symptoms
- Pain at site with erythema and/or edema (Correct answer)
- Pain at site with erythema and streak formation
- Palpable venous cord longer than 1 inch
Correct answer: Pain at site with erythema and/or edema
A Phlebitis Scale score of 2 indicates pain at the site with erythema and/or edema, indicating early phlebitis requiring intervention.
Question 5: How frequently should hospitalized patients' peripheral IV sites be assessed for complications?
- Every 8 hours
- Every 4 hours
- Every 12 hours
- Once per shift with a minimum of every 8 hours (Correct answer)
Correct answer: Once per shift with a minimum of every 8 hours
INS standards recommend assessing peripheral IV sites at a minimum of every 8 hours, or per institutional policy that may require more frequent checks.
Question 6: When removing a peripheral IV catheter, what is the correct post-removal action to prevent hematoma formation?
- Apply a tourniquet proximal to the site
- Apply firm, direct pressure for at least 2–3 minutes (Correct answer)
- Massage the site to disperse any blood
- Apply a warm compress immediately
Correct answer: Apply firm, direct pressure for at least 2–3 minutes
Firm, direct pressure for 2–3 minutes (longer for anticoagulated patients) is the standard to achieve hemostasis and prevent hematoma after IV catheter removal.
Question 7: Which type of dressing is recommended for central venous access device (CVAD) sites in patients with diaphoresis or when TSM dressings will not adhere?
- No dressing; leave site open to air
- Standard gauze and tape dressing changed every 2 days (Correct answer)
- Hydrocolloid dressing changed weekly
- Antimicrobial-impregnated gauze dressing
Correct answer: Standard gauze and tape dressing changed every 2 days
When TSM dressings will not adhere due to diaphoresis or other factors, gauze and tape is appropriate and should be changed every 2 days.
IV IV Site Care & Maintenance 1
According to INS standards, how often should transparent semipermeable membrane (TSM) dressings be changed on peripheral IV sites?