NCLEX-RN cheat sheet · Pharmacology
IV therapy and central lines
IV fluids, sites and site checks, peripheral complications, central lines, CLABSI, flushing and parenteral nutrition
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An IV is a direct line into the bloodstream, and a direct line for harm. A central line carries some of the highest infection risks in the hospital.
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At a glance
Three kinds of IV fluid
| Type | Examples | What it does | Watch |
|---|---|---|---|
| Isotonic | 0.9 percent saline, lactated Ringer's | Expands blood volume without shifting water into the cells. Replaces losses from bleeding, dehydration, shock, burns or diarrhea; raises blood pressure | Overload: caution with high blood pressure, heart failure, kidney disease |
| Hypotonic | 0.45 percent saline; dextrose 5 percent once its sugar is used | Moves water into cells: treats dehydrated cells. Diabetic ketoacidosis starts with isotonic fluid | Too much can cause brain swelling and low pressure |
| Hypertonic | 3 percent saline | Pulls water out of cells into the vessels: brain swelling or severe low sodium, usually in intensive care. Hypertonic saline isn't used to rehydrate in diabetic ketoacidosis | Overload: check blood pressure, breathing and the sodium level |
IV fluids are drugs: Check the rights, allergies, expiration and compatibility. IV electrolytes need the correct rate: potassium given too fast can stop the heart.
Equipment
- A pump is the safest way to give an exact amount. Gravity sets: macro-drip, 10, 15 or 20 drops per mL; micro-drip, 60, for children.
- Prime all tubing before connecting it, to keep air out. Keep the drip chamber a third to half full.
- A piggyback bag hangs higher than the primary bag, so it runs first.
- Lower gauge, wider catheter, faster flow. Usually 18 or 20 gauge for adults; 22 for frail older adults and children.
Sites and site checks
- Hand or arm, away from joints, under a clear dressing. Avoid an arm with a dialysis fistula, lymphedema, a clot, a fracture or heavy scarring.
- Breast surgery alone isn't a ban: assess axillary lymph-node treatment, existing lymphedema, access needs, policy, and any limb alert band.
- Site checks depend on the client, the therapy and the local standard; 4 hours is not a universal minimum. Check more often for children, vesicants, and clients who can't report symptoms.
Peripheral IV complications
| Problem | Signs | Action |
|---|---|---|
| Infiltration | Fluid leaking into the tissue: swelling, coolness, tight skin, leaking, slowed flow or pump alarms | Stop the infusion and remove the catheter; restart at a new site. Flushing pushes more fluid into the tissue |
| Extravasation | A vesicant leaking into the tissue: burning, blisters, or tissue death | Stop it, disconnect the tubing, and draw back from the hub before removing the catheter; then follow the drug's policy |
| Phlebitis, infection | Inflamed vein: redness, pain, warmth, swelling, sometimes a hard cord. Infection: pus | Pus: remove the catheter and culture it |
| Fluid overload | Falling oxygen saturation, fast breathing, crackles, restlessness, pink frothy sputum | Slow or stop the infusion per protocol, raise the head of the bed, give oxygen, check vital signs, and call the provider at once |
| Suspected venous air embolism | Sudden shortness of breath, coughing, chest or shoulder pain | Clamp to stop the air, give oxygen, call a rapid response; if allowed, turn left side, head down. Positioning differs for arterial or cerebral air |
Removing an IV: Clamp the line, loosen the dressing toward the site, and pull parallel to the skin. Hold pressure until the bleeding stops, then reassess; clients on anticoagulants may need longer. Check that the tip is intact: a missing piece can travel in the bloodstream, so report it at once.
Central venous access devices
| Device | Key points |
|---|---|
| PICC | An arm vein, as long as clinically indicated: no universal 6-month maximum. Not in end-stage kidney disease, to save veins for dialysis |
| Non-tunneled | Days to weeks. Subclavian lowers infection, but weigh insertion risks and avoid it in hemodialysis or advanced kidney disease. Adults: avoid the femoral vein |
| Tunneled | Runs under the skin to an exit site, which helps keep germs out. Long-term therapy, like chemotherapy |
| Implanted port | A small reservoir under the skin below the collarbone, reached with a noncoring needle |
Before first use: Insertion needs informed consent. The tip's position is confirmed, often by chest X-ray, before the line is used.
Preventing CLABSI
- Bundle: hand hygiene, full barrier precautions at insertion, chlorhexidine skin prep.
- Ask every day whether the line is still needed, and remove it promptly when it isn't.
- Before every access, scrub the hub with friction for at least 15 seconds, then let it dry.
- Dressings: gauze every 2 days, transparent every 7, or sooner if damp, loose or soiled.
Flushing
- Draw back for a blood return, then flush with sterile 0.9% saline.
- 10 mL or larger syringe: smaller syringes create more pressure, which can rupture the catheter.
- Never flush against resistance. Blocked? Check kinks and clamps, then reposition: raise the arm, cough and breathe deeply, or stand and sit. A thrombolytic may be ordered.
Central line complications
| Problem | Action |
|---|---|
| Infection: redness, swelling, drainage or tenderness at the site, or a rising white count | Notify the provider, expect blood cultures, follow the sepsis protocol. The line may be removed and its tip cultured |
| Slipped out partway | Measure the external length. Never push it back in; notify the provider |
| Out all the way | Press firmly; an air-occlusive sterile dressing; a colleague calls rapid response |
| Catheter breaks | Clamp near the insertion site; cover with sterile gauze; keep scissors away |
| Suspected venous air embolism: sudden shortness of breath, coughing, chest pain, or confusion | Stop the air entry, call rapid response, give high-flow oxygen; if allowed, left side, head down. Prevent it: hubs closed, clamps engaged |
| Pneumothorax after a neck or chest insertion: sharp chest pain on breathing in, breathlessness, dry cough | Call rapid response, give high-flow oxygen, and expect a chest tube |
Parenteral nutrition (PN)
- Glucose, amino acids, electrolytes and vitamins, often with lipids, pumped usually through a central line. Used when the gut can't be used, like a prolonged ileus, or can't meet needs; if the gut works, enteral feeding comes first.
- Too much dextrose: high glucose, hyperosmolar coma, and death. Check glucose, and give insulin as ordered. Severe malnutrition: refeeding syndrome can drop potassium, phosphorus and magnesium, so levels are checked and feeding starts slowly.
- A dedicated line, a 1.2 micron filter when lipids are included, no other drugs added. Don't draw blood from the PN lumen. Bag with additives: used within 24 hours; lipid through a Y-connector: within 12.
Priority and safety calls
- ★ Swollen, cool, tight site with pump alarms: stop the infusion and remove the catheter, then restart at a new site. Don't flush it.
- ★ Sudden shortness of breath and chest pain after a bag change or an open hub: stop air entry, give oxygen, call a rapid response.
- Resistance when flushing a central line: stop, check kinks and clamps, reposition, and report it if it stays blocked.
- PN glucose of 286 mg/dL: report it, and expect glucose checks and insulin as ordered.
How the NCLEX tests it
- Isotonic replaces volume, hypotonic hydrates cells, hypertonic pulls water into the vessels.
- Traps: hypertonic fluid in diabetic ketoacidosis, flushing an infiltrated line, an IV in a restricted arm.
- Infiltration and extravasation: stop and remove. Overload: slow or stop it, sit up, oxygen, call.
- Traps: flushing against resistance, a small syringe, pushing a slipped catheter back in, labs from PN lumen.
- Poorest PICC candidate: end-stage kidney disease, to preserve arm veins for dialysis.
Practice it next
This sheet comes from IV therapy and peripheral lines and Central lines and parenteral nutrition in our NCLEX-RN course. Try free practice questions, or see the lessons it was written from.
Quick self-quiz
- 3 percent saline is ___, and it isn't used to rehydrate in diabetic ketoacidosis.
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hypertonic - Flush a central line with a ___ mL or larger syringe.
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10 - Scrub the hub with friction for at least ___ seconds.
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15 - An implanted port is reached with a ___ needle.
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noncoring - PN with lipids runs through a ___ micron filter.
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1.2
Sources
- Open RN, Nursing Skills 2e, 23.2 IV Therapy Basics
- Open RN, Nursing Skills 2e, 23.4 IV Therapy Site Assessment and Complications
- Open RN, Nursing Advanced Skills, 4.2 Basic Concepts (central lines)
- CDC, Intravascular catheter-related infections: summary of recommendations
More pharmacology cheat sheets
- Anticoagulants and clotting NCLEX cheat sheet
- Medication safety and high-alert drugs NCLEX cheat sheet
- Dosage calculation NCLEX cheat sheet
- Drug-name stems NCLEX cheat sheet
Educational use only. This sheet is a study aid for the NCLEX-RN, not a substitute for clinical judgment, your facility’s policy or the provider’s orders. Where practice varies, follow facility policy and state law. NCLEX® and NCLEX-RN® are registered trademarks of NCSBN, which does not endorse these materials.