IV IV Site Care & Maintenance 3

Question 1

Which flushing solution and volume is the standard recommendation for maintaining a non-valved PICC between uses?

Accepted Answer

Normal saline 10 mL using pulsatile push-pause technique, followed by a positive-pressure lock

Answer

Sterile water, 5 mL

Answer

Heparinized saline 10 units/mL, 10 mL

Answer

Normal saline 3 mL with gentle continuous push

Question 2

What differentiates extravasation from infiltration at an IV site?

Accepted Answer

Extravasation involves leakage of a vesicant or irritant solution capable of causing tissue necrosis

Answer

Infiltration involves a vesicant solution; extravasation involves only isotonic fluids

Answer

Infiltration causes more severe tissue damage than extravasation

Answer

There is no clinical difference — the terms are interchangeable

Question 3

A peripheral IV catheter site has been in place for 5 days with no signs of complications. Per current INS standards, what should the nurse do?

Accepted Answer

Leave the catheter in place if there are no clinical signs of complications

Answer

Remove and replace the catheter at a new site immediately

Answer

Request a physician order to extend the dwell time

Answer

Replace the catheter in the same vein to preserve venous access

Question 4

When applying a transparent semipermeable dressing to a peripheral IV site, why is it important to avoid stretching the dressing?

Accepted Answer

Stretching can cause tension injury (medical adhesive-related skin injury) when the dressing contracts

Answer

Stretching increases the cost of dressing use

Answer

Stretched dressings absorb moisture more efficiently

Answer

Stretching reduces the adhesive surface area and causes early dressing failure only

Question 5

What is the recommended action for a peripheral IV catheter that has a clot or sluggish flow but is otherwise without signs of infection or infiltration?

Accepted Answer

Remove and replace the catheter at a new site

Answer

Irrigate forcefully with a 10 mL syringe of normal saline to dislodge the clot

Answer

Aspirate the clot and then flush with heparin

Answer

Apply a warm compress to the arm for 15 minutes and retry

Question 6

Which of the following is a key element of the SASH (or PASS) flushing protocol used for central venous access devices?

Accepted Answer

Saline → Administer medication → Saline → Heparin lock

Answer

Alcohol wipe → Saline → Medication → Saline

Answer

Saline → Assess → Suture → Heparin

Answer

Push medication → Assess return → Saline → Seal

Question 7

A nurse is caring for a patient with a tunneled central catheter whose exit site dressing has a small amount of dried blood from post-insertion day 1. What is the correct dressing management?

Accepted Answer

Change the dressing immediately using sterile technique and reassess

Answer

Leave the dressing in place until the first scheduled change at 48 hours

Answer

Apply a new dressing layer on top of the existing one

Answer

Remove the dressing and leave the site open to air until bleeding resolves