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IV

Therapy
Module

Welcome to the IV Therapy


Module!

Follow the steps below to successfully


establish competence.

IV Therapy Module Objectives:

At the completion of this module, the


caregiver will be able to discuss the
indications, complications, and key steps
for initiating IV therapy.
The caregiver will also be able to identify
and discuss the considerations associated
with selecting and maintenance of IV sites.
(*Revised 9-2003)

Step #1
Read the attached module. The learning activities may be
used as a study guide. This module has been designed to
be completed within 30-45 minutes.

Step #2
The participant should complete and return the post-
test.
IV Therapy IV Therapy
Learning Activity
In the health care environment vascular
access is performed to deliver fluid and
medication, as well as for sampling the blood
and it's components.

Children report needlesticks to be the most


distressing aspect of a hospital or out-patient
experience. The following principles of care
are integral to efforts to minimize needle
related pain and distress in children –
• Avoid or cluster needlesticks whenever
possible
• Use the IM route only if absolutely
necessary
Before the caregiver can perform • intervene early - if a child has a difficult
vascular access they should have an experience with their initial venipuncture
understanding of the following: / IV start they will have heightened
anxiety around subsequent procedures
• Be developmentally appropriate

Before the caregiver can perform vascular


access they should have an understanding of
the following:
• Vascular anatomy and physiology
• Basic steps for performing access
• Complications and hazards
• Growth and developmental implications

This module is intended to be an introduction


to vascular access. The caregiver should seek
out additional specific information (i.e., policy
and procedure) when performing vascular
access in their area.

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IV Therapy IV Therapy
Learning Activity
Basic Vascular Anatomy and Physiology
Fill-In the names of the vessels in The circulatory system consists of a series of
order as they exit the heart. blood vessels. The blood vessels in the human
body form a network of tubes that carry
Exiting the Heart blood away from the heart, transport it to the
tissues of the body, and then return it to the
heart.
_______________________ Arteries are vessels that carry blood from
the heart to the tissues. Large, elastic
arteries leave the heart and divide into
_______________________ medium-sized, muscular arteries that branch
out into the various regions of the body.
Arterioles are smaller -sized arteries that
divide from medium arteries. Arterioles enter
_______________________
tissues, and branch into countless microscopic
vessels.
Capillaries are the microscopic vessels found
_______________________
in the tissues. Through the walls of the
capillaries, substances are exchanged between
the blood and body tissues.
_______________________ Venules are the small veins that are formed
from groups of capillaries reuniting before
Back to the heart leaving the tissues.
Veins are the larger vessels formed from the
venules which convey blood from the tissues
back to the heart.

Due to the design of the body's circulatory


system the arteries receive blood being
pumped directly from the heart. As a result
arteries can be classified as high pressure /
pulsatile vessels. Since the veins are the last
vessels involved with returning blood to the
heart they can be referred to as low pressure
/ non-pulsatile vessels.

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IV Therapy IV Therapy
"Learning Activity"
The pressure in the veins is barely enough to
balance the force of gravity pushing blood
back down to the lower limbs. For this reason
many veins, especially those in the limbs,
contain valves to prevent backflow.
Explain how the veins prevent the
backflow of blood in the lower limbs
due to the force of gravity. Indications for Vascular Access
_____________________________ The indications for vascular access may
___________________________ include the following:
_____________________________ • fluid replacement
• blood sampling
• medication delivery
• parenteral nutrition

Selecting A Site for Access


Site selection is one of the most important
considerations in preparing to start an IV or
to obtain blood. The caregiver should always
start from the most proximal portion of the
Indications For Vascular Access may
extremity and move toward the distal. In
include: (Fill-In)
addition, always remember to keep the number
of attempts to a minimum (see hospital policy
___________________________ and procedure for the maximum number of
___________________________ attempts permitted by one individual).
___________________________
When selecting the site for venous access the
___________________________
caregiver should consider the following:
l purpose and duration of IV therapy
l age of the child
l condition of the veins
l skin integrity
l patient preference

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IV Therapy IV Therapy
"Learning Activity"
Purpose and Duration
Describe why the purpose and duration
of an IV is important to consider? As the length of time for IV therapy
increases, the patient's comfort and level of
_________________________ immobilization required becomes more
important to consider.
_________________________
Ideally, the patient should receive the type of
access appropriate for diagnosis
(epidermolysis bullosa, cystic fibrosis,
Describe when and why the lower osteomyelitis, sickle cell anemia). For example,
extremities are commonly avoided if a patient requires IV therapy for a long
when selecting and initiating an IV. duration, they may require a more durable
form of access (i.e. peripherally inserted
_____________________________ central catheter or PICC).
_____________________________
_____________________________ The caregiver should also ensure that the site
selected and type of line selected will best
support medications / fluids that may be
irritating to the veins (i.e., Vancomycin,
calcium and fluids with high dextrose
concentration).

Selecting A Site For Access

Age of The Child

The caregiver should be sensitive to patient’s


age when selecting and initiating an IV. For
example, if the child is walking, the lower
extremities are commonly avoided due to the
increased risk of thrombophlebitis, and the
limitations it may place on the patient’s
mobility. The caregiver should also avoid the
patient’s “thumb-sucking digit.”

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IV Therapy IV Therapy
"Learning Activity"

Condition of The Veins

The ideal site for venous access is the vein


The ideal site for venous access is the that can be visualized or palpated, smooth
vein that can be and straight enough to accept the catheter.
__________________or Veins that have been damaged by frequent use
_____________, and / or irritated by caustic medications
__________________ and should be avoided. These sites can be
_____________ enough to accept identified upon visual inspection as well as by
the catheter. (Fill-In) transillumination.

The characteristics common to damaged and /


or irritated sites include: scarring, bruising,
List the characteristics common to swelling, altered skin integrity (i.e., blister).
damaged and / or irritated sites.
The presence of valves in the veins may cause
1.___________________________ problems with proper vein cannulation.

2.___________________________
Patient Preference
3.___________________________
Whenever possible, especially with school-
4.___________________________ aged patients, their desires and knowledge
should be considered. Often the older child or
parent may be able to tell the caregiver which
sites they prefer as well as which sites have
been successfully cannulated upon previous
attempts.

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IV Therapy IV Therapy
"Learning Activity"
Specific IV Sites

The ______________ and the Upper Extremity


_________ veins in the forearm are
the most commonly used in the upper The cephalic, basilic, and median cubital veins
extremity. in the forearm are most commonly used in the
upper extremity.
Often, the median cubital is attempted first.
Often times the ________________ This may pose a problem in the future should a
is attempted first. midline or a peripherally inserted central
catheter (PICC) be needed by the child.
IN the dorsum of the hand, the most In the dorsum of the hand, the most commonly
commonly used veins include tributaries used veins include the tributaries of the
of the _________ _________ as well cephalic and basilic veins as well as the dorsal
as the ___________ arch. venous arch.

Lower Extremity
The __________________ vein at
the ankle is probable easiest to The saphenous veins, the median marginal
cannulate. veins, and the veins of the dorsal arch of the
lower extremity may be accessed. Of these
veins, the great saphenous vein at the ankle is
probably easiest to cannulate.

Scalp Veins

The use of scalp veins may be more


The use of _____________ veins may appropriate for infants. Due to the fragility
be more appropriate for infants. of the infant’s vessels, the caregiver should
frequently assess the site for complications.
The caregiver should always remember to
insert the IV in the direction of the heart. To
The caregiver should always remember avoid puncturing an artery, the caregiver
to insert the IV in the direction of the should always palpate for a pulse prior to a
____________. venipuncture.

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IV Therapy IV Therapy
"Learning Activity"
Growth and Development Considerations

Children are special individuals with their own


It is our responsibility to help the needs. As they enter the hospital setting,
children ____________________ to many tests and procedures are done which are
have _________________ and to use different to them and at times invasive. It is
our _____________________ when our responsibility to help the children feel at
available. ease, to have patience with them, and to use
our resources when available (i.e., Child Life).

Prior to initiating an IV the caregiver should


always communicate what the procedure may
entail using appropriate terminology and
support measures.

Preparation and Pain Management


Behavioral and pharmacologic interventions
should be combined in an effort to relieve
anxiety and pain.

The caregiver should always be Behavioral Interventions


__________ but yet be careful not to • Parental presence is comforting to children
use terms that may ___________ the and should be promoted whenever possible
patient and their support systems. • Be honest – explain in simple language what
child will see, hear, taste, smell and feel
using words, pictures and dolls
List some Behavioral Interventions that • Treatment rooms, if available, should be
can be used to relieve anxiety and pain: used for venipuncture so that a child can
rest and relax in their bed
• Utilize “Positioning for Comfort” – a
therapeutic approach to positioning
children for painful procedures, which aims
to minimize a child’s feelings of
helplessness and vulnerability while
promoting feelings of security and control.
• Refer to “Needle Pain Guidelines” for
further age appropriate interventions

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IV Therapy IV Therapy
"Learning Activity"

Pharmacologic Interventions
List some Pharmacoloic Interventions • Children report that EMLA helps .. use it !
that can be used to relieve anxiety and • If it will be less than 20 minutes before
pain: the needlestick, utilize Fluorimethane
(Cold Spray) immediately before
venipuncture
• If 30 –90 minutes is available before the
needlestick, apply EMLA to potential
venipuncture sites
• Refer to “Needle Pain Guidelines” for
dosage & administration information.

Child Life recommends that a consistent staff


member or members conduct procedures. (i.e.,
blood draw, IV initiation)

If available, Child Life should always be


contacted to assist in preparing the patient
and in providing diversional activities during
the procedures. The caregiver may find it
helpful to review the module “Impact of
Illness on Growth and Development”.

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IV Therapy IV Therapy
"Learning Activity"

Fill-In the missing steps for Key Steps for Initiating Peripheral IV
“Initiating Peripheral IV Therapy” Therapy
1. Perform patient / family teaching and
Perform _________ / __________ apply EMLA cream if > 30 minutes to
teaching and apply procedure (refer to growth and
___________________ if > 30 developmental considerations). If patient
minutes to procedure has undergone venipuncture before ask
what helped them in the past.
2. Assemble equipment, prepare tape, flush
Assess the patient for ___________ catheter and tubing if desired and if not
sensitivity, and any other collecting labs. Assess the patient for
_________________. latex sensitivity and any other allergies
(see policy and procedure for specific
equipment).
Take patient to 3. Take patient to treatment room (if
_____________________________. available) and initiate behavioral supportive
measures (e.g. positioning for comfort,
distraction, relaxation) as appropriate.
Put on _________and any other 4. Perform hand washing.
protective barriers. 5. Put gloves on and any other protective
barriers.
6. Select the site. The caregiver may find it
Select the ____________________. helpful to use a tourniquet to locate a site.
7. Prepare the skin, wipe with alcohol, allow
to dry, then wipe with providine (allow 30
Prepare the skin with seconds for skin contact).
________________. 8. Provide counter-traction on the skin, with
the other hand, insert needle/catheter at
a 10 - 30 degree angle, with bevel up,
Provide ____________ either over or beside the vein.
traction______________ 9. Slowly advance the catheter until blood
_____________________________ returns, then lower the catheter and
____________ continue to advance, just enough to cover
the stylet and catheter in the vein, then
hold catheter and withdraw stylet enough
Slowly advance the needle/catheter to “hood” in side of catheter, then grasp
until___________. the stylet and catheter together and
continue to advance to the hub.

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IV Therapy IV Therapy
"Learning Activity" Key Steps for Initiating Peripheral IV
Therapy
Continued
Attach the ___________________
to the catheter followed by slowly 10. Remove the tourniquet if in use.
flushing it with normal saline. 11. Secure catheter in place using a sterile
transparent occlusive dressing.
Loop the tubing and t-connector near 12. Attach the T-connector to the catheter
the ________________________ followed by slowly flushing the system with
and secure with tape, normal saline. Observe for signs of
infiltration and / or hematoma.
Leave the T-connector exposed to 13. You may now chevron ¼ inch tape over the
permit ____________________ occlusive dressing.
when required. 14. Loop the tubing and t-connector near the
site of entry and secure with tape, leave the
T-connector exposed to permit tubing
change when required.
15. Apply armboard, pad as necessary, to
provide protection.
16. Mark the date, time, type and size of
catheter used in appropriate place (i.e.,
chart, notes) per policy and procedure.
17. Adjust rate of solution flow according to
amount prescribed or flush the site lock to
maintain patency for intermittent use.
18. Observe and document patient's response /
tolerance – ask patient “how was that for
you?”, what helped, what didn’t?
19. Perform hand washing.

When performing phlebotomy, the caregiver


will perform steps 1-8, then collect the
specimen per policy and procedure.

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IV Therapy IV Therapy
"Learning Activity"
When maintaining an IV the caregiver may find
it helpful to perform a quick review of the
following:

Right solution?

Appropriate volume and rate of flow per


patient weight?
√ Circulatory overload can occur more quickly
IV Checklist and have more serious effects in children.
When maintaining an IV the caregiver
may find it helpful to perform a quick Right equipment? Are system alarms
review of the following: (Fill-In) functional?
√ When working with children, medications /
fluids should be administered with devices
___________________________
that permit accurate delivery (i.e., pumps).

___________________________ Right labeling?


√ Labeling should include fluid, medications (if
___________________________ medication has been added), date, and time
bottle / bag was hung and date and time to
___________________________ be changed per policy and procedure.

Patency of the tubing?


___________________________
√ Check for kinks, air, blood, leaks and
flattening.
___________________________
Are the clamps out of the child’s reach?
___________________________
Is the site free from complications?
___________________________ √ Pain / Tenderness
√ Swelling
√ Warmth or coolness
___________________________
√ Blanching
√ Redness
___________________________ √ Vein hardness
√ Wetness
___________________________ √ Patency of overall system, including the site

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IV Therapy IV Therapy
"Learning Activity"
Is the site free from complications?
√ Vital signs (alterations can indicate IV
complications).
√ Urine Output
√ Visible edema
√ Cough or frothy sputum (may indicate fluid
overload).
√ General appearance of the child
√ Fluid balance record (I & O) should be
current for hourly and running volume
totals.

How frequently should the dressing be How frequently should the dressing be
changed? (Fill-In) changed?
_____________________________ It is generally recommended that the dressing
_____________________________ be changed as needed when it becomes non-
_____________________________ occlusive and / or soiled.
Otherwise, the caregiver should refer to the
policy and procedure for the specific protocol
regarding the frequency of dressing changes
for IV sites.
How frequently should the site be
changed? (Fill-In) How frequently should the site be changed?
_____________________________ Peripheral IV sites should be changed as
_____________________________ needed, such as if signs of infiltration, phlebitis
_____________________________ or infection occur. Surgically implanted types
of access (i.e., portacaths) are generally re-
accessed in as few as 7 days or as many as 30
days depending upon frequency of use. The
caregiver should refer to the policy and
How often should the site be checked? procedure for specific protocol.
(Fill-In)
_____________________________ How frequently should the site be checked?
_____________________________ It is generally recommended that IV site be
_____________________________ checked at least every 1-2 hours.

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IV Therapy
"Learning Activity" IV Therapy

Children may have IV’s for the purpose Caring for An Intermittent System
of Children may have IV’s for the purpose of
_____________________________ continuous and / or intermittent infusion of
medications and /or fluids.
and / or If the child has an IV for intermittent therapy
only, a site lock system (e.g. heparin lock) may
be used. The site lock system need only be
infusion of medications and / or fluids. accessed when the medications and / or fluids
(Fill-In) are administered.
The site lock system may be a rubber chamber
or device into which the IV infusion set (e.g.
needless cannula) is inserted. Once the infusion
is completed the caregiver should carefully
remove the infusion equipment leaving the site
lock intact. Site locks are usually flushed with a
heparinized saline solution to prevent clotting in
the cannula between infusions.
The caregiver should check the current policy
and procedure regarding the protocol for
selecting a flush solution.
When performing vascular access for Site locks are ideal for short-term therapy, and
IV initiation the caregiver should may allow children the opportunity to maintain
observe for the following such therapy independently at home.
complications: (Fill-In)

._________________________ Complications Associated With Performing


Vascular Access
._________________________

._________________________ When performing vascular access for IV


initiation the caregiver should observe for the
._________________________ following complications: infiltration, phlebitis,
circulatory overload, air embolism, infection,
._________________________ clotting at the site, and skin irritation. If
observed, notify physician/designee and
._________________________
document as per current charting policy. Refer
._________________________ to appropriate policy for further treatment.

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IV Therapy IV Therapy
"Learning Activity"
Infiltration
Infiltration may be caused by needle / catheter
Describe the signs and symptoms of displacement and or blood leakage from the
infiltration. vein.

Signs and symptoms


_____________________________ • site swelling
• cool skin at site
_____________________________ • poor blood return and sluggish flow.

Describe the suggested interventions Interventions include:


for treating infiltration. • stop the flow
• remove needle or catheter.
_____________________________

_____________________________ Phlebitis
Phlebitis may be caused by injury to the vein
___________________________ associated with movement of the needle, or
improper immobilization, too slow of a flow rate,
overuse of the vein, and / or use of irritating
Describe the signs and symptoms solutions.
phlebitis
Signs and symptoms include:
_____________________________ • sluggish flow
____________________________ • warm-red site
• swelling
Describe the suggested interventions • hardness along the vein site
for treating phlebitis. • streaking on the skin along the tract of the
catheter and / or the vein
_____________________________ • site pain and / or tenderness
_____________________________ • possible mild fever

Interventions:
• stop the flow,
• remove needle or catheter
• apply warm-moist compresses.

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IV Therapy IV Therapy
"Learning Activity"
Infection
Describe the signs and symptoms of Infection may be caused by improper aseptic
infection. technique during the initiation of an IV and / or
____________________ poor maintenance. In addition the caregiver should
____________________ note that the immunocompromised patient might
____________________ be particularly susceptible to infection.
____________________
____________________ Signs and symptoms include:
____________________ • site pain and / or tenderness
____________________ • swelling
____________________ • foul-smelling discharge
____________________ • elevated temperature
____________________ • chills
• blood culture positive for pathogens

Interventions include:
• discontinue the IV
• Seek a physician/designee’s order for local
and /or systemic therapy

Describe the suggested interventions Air Embolism


for treating infection. Air embolism may be caused by tubing improperly
___________________________ cleared of air.
___________________________
Signs and symptoms include:
Describe the signs and symptoms of • cyanosis
air embolism. • decrease in blood pressure
• weak rapid pulse
___________________________ • loss of consciousness
___________________________ • other clinical observations indicative of shock

Describe the suggested interventions Interventions include:


for treating air embolism. • notify the physician immediately
• give oxygen as necessary
___________________________ • inspect system for air leaks
___________________________ • turn child on left side

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IV Therapy IV Therapy
"Learning Activity"
Circulatory Overload
Circulatory overload may be caused by a “too fast
Describe the signs and symptoms of flow rate” and / or a “too large volume infused.”
circulatory overload.
____________________ Signs and symptoms include:
____________________ • elevated blood pressure
____________________ • tachycardia
____________________ • increased urine output
____________________ • possible distention of the neck veins, gallop (an
____________________ additional sound heard in the heart due to
____________________ excessive fluid filling, may sound like “horses
____________________ running”)
____________________ • periorbital edema
____________________ • bulging fontanel
________________________ • dyspnea
• rales
• cough
Describe the suggested interventions • frothy sputum
for treating circulatory overload.
___________________________ Interventions include:
___________________________ • notify physician
___________________________ • slow the infusion to "keep vein open" (KVO)
___________________________ • raise the child to semi or high fowlers
___________________________ • give oxygen as needed
___________________________ • assist respirations as needed

Clotting/Occlusion
Describe the signs and symptoms of
clotting/occlusion. Clotting / occlusion may be caused by:
• too slow a drip rate
___________________________ • inappropriate flushing to maintain patency
___________________________ • bleeding disorders
_______________ • IV running dry
• kinking of the catheter preventing flow
• drug incompatibilities
• the extended duration of use of site

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IV Therapy IV Therapy
"Learning Activity"
Signs and symptoms include:
• no blood return upon aspiration
Describe the suggested interventions • occluded IV flow
for treating clotting/occlusion. • inability to flush
• infiltration
___________________________
___________________________ Interventions may include:
_______________ • discontinue IV
• restart if possible
Describe the signs and symptoms of • monitor drip rate more closely
skin irritation.
____________________ Skin Irritation
____________________ Skin irritation may be caused by injury to the skin
____________________ due to taping, restraints, infiltration, and / or
____________________ pressure.
____________________
____________________ Sign and symptoms include:
____________________ • redness at site
____________________ • raised-irritated areas
____________________ • itching and burning around the tape
____________________
________________________ Interventions include:
• remove irritant
• reapply dressing over insertion site
Describe the suggested interventions (hypoallergenic tape is available)
for treating skin irritation. • Re-investigate for allergies to skin prep,
dressing and / or latex to avoid future
exposure
• Seek a physician/
designee order for
topical therapy.

IV Therapy 09/2003 18
IV Therapy Module Resources

Broadwell Jackson, Debra and Rebecca B. Saunders. Child Health Nursing. Philadelphia: J.B.
Lippincott, 1993.

Taylor, Carol, et. al., Fundamentals of Nursing - The Art and Science of Nursing Care.
Philadelphia: J.B. Lippincott, 1993.

Textbook of Pediatric Advanced Life Support. American Heart Association, 1997.

Whaley, Lucille F. and Donna Wong. Clinical Manual of Pediatric Nursing. St. Louis: C.V.
Mosby Company, 1995.

IV Therapy 09/2003 19
IV Therapy Post Test

Name: Date:

Department:

1. Select from below the indications for performing vascular access

a. fluid replacement
b. medication delivery
c. enteral nutrition
d. IV blood sampling
e. a, b, and d are correct

2. Choose the statement which best describes how to select a site for IV initiation and / or
obtaining a blood sample.

a. The caregiver should always start in the proximal portion of extremity and move more
distal.
b. The caregiver should always start in the distal portion of the extremity and move more
proximal.
c. The caregiver should select only the sites that have never been used.
d. The caregiver should select only the site the patient agrees upon.

3. When selecting the site for venous access the caregiver should consider the following:

a. patient’s ability to pay


b. purpose and duration
c. age of the child
d. skin integrity
e. b, c, and d are correct

4. Scarring, blisters, swelling, and bruising are all characteristics common to a damaged and/or
irritated site.

a. true
b. false
5. Select the statement which best describe the technique performing venous access.

a. to prepare the skin, wipe with povidine (allow 30 seconds for skin contact), followed by
alcohol.
b. to prepare the skin, wipe with sterile gauze, followed by providine.
c. to prepare the skin, wipe with alcohol.
d. to prepare the skin, wipe with alcohol, followed by providine (allow 30 seconds for skin
contact).

6. When performing IV maintenance, the caregiver should check that he/she has the right
solution, right labeling, right equipment, the appropriate volume and rate of flow per patient
weight, and that the site is free from complications.

a. true
b. false

7. Signs and symptoms associated with infiltration include:

a. site swelling
b. poor blood return
c. cool skin at site
d. all of the above

8. If a patient with an IV should develop cyanosis, weak rapid pulse, loss of consciousness, and
other signs indicative of shock, you should suspect an air embolism.

a. true
b. false

9. If an air embolism is suspected, the caregiver should turn the child to the left side, give
oxygen as needed, and notify the physician/designee immediately.

a. true
b. false

10. It is generally recommended that a peripheral IV site be changed as needed.

a. true
b. false

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