IV IV Site Care & Maintenance 2 — Questions and Answers
Question 1: What is the recommended 'scrub the hub' technique for disinfecting a needleless connector before access?
- Wipe once with an alcohol swab and access immediately
- Scrub vigorously with 70% alcohol or CHG-alcohol for at least 5–15 seconds and allow to dry (Correct answer)
- Spray with antiseptic and access immediately without drying
- Wipe with povidone-iodine and access after 30 seconds
Correct answer: Scrub vigorously with 70% alcohol or CHG-alcohol for at least 5–15 seconds and allow to dry
Vigorous mechanical scrubbing with 70% isopropyl alcohol or CHG-alcohol for 5–15 seconds followed by drying is required to disinfect needleless connectors and prevent CLABSI.
Question 2: A chlorhexidine gluconate (CHG) patch/disc is indicated for use at which type of IV access site?
- Peripheral IV sites in all adults
- Short-term peripheral catheter sites in neonates
- Central venous access device (CVAD) insertion sites (Correct answer)
- Subcutaneous infusion sites
Correct answer: Central venous access device (CVAD) insertion sites
CHG-impregnated dressings are indicated for CVAD insertion sites to reduce the risk of CLABSI by providing sustained antimicrobial activity.
Question 3: How often should the administration set (IV tubing) for continuous infusions be changed in the absence of blood product or lipid administration?
- Every 24 hours
- Every 48 hours
- Every 72–96 hours (Correct answer)
- Every 7 days
Correct answer: Every 72–96 hours
INS and CDC recommend changing primary and secondary continuous administration sets no more frequently than every 96 hours (4 days) unless indicated otherwise.
Question 4: When should administration tubing used to infuse blood or blood components be changed?
- Every 4 hours
- After every unit or after 4 hours, whichever comes first (Correct answer)
- Every 24 hours
- Only when visibly soiled
Correct answer: After every unit or after 4 hours, whichever comes first
Blood administration tubing should be changed after each unit of blood product or after 4 hours of infusion time, whichever occurs first, to reduce bacterial proliferation risk.
Question 5: What is the first nursing action when a peripheral IV site shows signs of infiltration?
- Slow the infusion rate and reassess in 30 minutes
- Discontinue the IV and remove the catheter (Correct answer)
- Notify the physician before taking any action
- Apply a warm compress and continue the infusion
Correct answer: Discontinue the IV and remove the catheter
The immediate action for IV infiltration is to stop the infusion and remove the catheter to prevent further tissue damage from continued fluid extravasation.
Question 6: To confirm PICC line tip placement prior to initiating infusion, the nurse should review:
- The post-insertion chest X-ray report confirming tip in the lower third of the superior vena cava or cavoatrial junction (Correct answer)
- Nurse's visual assessment of the external catheter length
- Blood return upon aspiration only
- Patient comfort at the insertion site
Correct answer: The post-insertion chest X-ray report confirming tip in the lower third of the superior vena cava or cavoatrial junction
Radiographic confirmation of tip placement at the lower third of the SVC or cavoatrial junction is mandatory before using a PICC for any infusion.
Question 7: A nurse notes that a PICC dressing is partially lifted and moist on post-insertion day 3. What is the correct action?
- Reinforce the dressing with additional tape and document
- Change the dressing immediately using sterile technique (Correct answer)
- Leave the dressing and schedule a routine change for day 7
- Remove the PICC and insert a new peripheral catheter
Correct answer: Change the dressing immediately using sterile technique
A compromised (wet, soiled, or partially detached) CVAD dressing must be changed immediately using sterile technique regardless of scheduled change intervals.
IV IV Site Care & Maintenance 2
What is the recommended 'scrub the hub' technique for disinfecting a needleless connector before access?