▶How do you select the best vein for IV insertion and what are the preferred sites?
First choice for adults is the antecubital fossa (median cubital, cephalic, or basilic vein) because veins are large, visible, and easy to anchor. Second choice is the hand or forearm (dorsal hand, cephalic, or basilic vein). Avoid the legs in ambulatory patients (infection and DVT risk), the dominant arm (patient cannot use it), and areas with bruising, scarring, mastectomy (lymphedema risk), or dialysis fistula. For pediatrics and difficult veins, a scalp vein in infants or a heel vein can be used. Assess vein quality by palpation (bouncy and springy is good; hard and sclerosed is bad). Avoid areas of inflammation, infection, or recent extravasation. In very sick patients (severe dehydration, burns, shock), the external jugular or saphenous vein may be necessary but should be placed by an experienced clinician. Document the site (e.g., 'left cephalic antecubital') so that the IV is not pulled or kinked.
▶What is the correct technique for peripheral IV insertion and how do you confirm placement?
Use sterile technique: clean hands, don gloves, clean the site with chlorhexidine or alcohol in a circular motion for 30 seconds and let dry (air drying or sterile gauze, never blowing). Apply a tourniquet proximal to the site but not so tight that blood flow is completely blocked (you should still feel a pulse). Insert the IV catheter (needle + plastic catheter) at a 10–30 degree angle, bevel-up, into the vein. You will feel a 'flash' of blood in the chamber when the needle enters the vein. Advance the needle and catheter a bit further into the vein, then slide the plastic catheter over the needle into the vein while withdrawing the needle. Never reinsert the needle into the catheter (sharp tip can puncture the catheter and cause thromboembolism). Remove the tourniquet, apply pressure above the catheter tip, and connect the IV tubing or saline flush. Confirm placement by: (1) drawing back blood easily; (2) observing fluid flowing freely without extravasation; (3) noting no pain or swelling at the site. Secure the catheter with sterile tape (H-strap or chevron) and cover with a transparent dressing so the site is visible for monitoring.
▶What are the main complications of IV therapy and how do you prevent and manage them?
Infiltration: IV fluid leaks into surrounding tissue, causing swelling and pain. Prevention: secure the catheter firmly, tape the tubing to prevent pulling, check the site every hour, and keep the patient's arm in a neutral position (not bent). Management: remove the IV immediately, elevate the arm, apply warm or cold compress depending on fluid type (potassium is tissue-damaging; apply ice). Phlebitis: inflammation of the vein due to irritating fluid (potassium, hypertonic solutions, certain antibiotics) or prolonged catheter dwell time (>72–96 hours). Prevention: change IVs every 72–96 hours, use largest appropriate vein, flush regularly, and avoid irritating drugs through peripheral lines if possible (use central line instead). Management: remove the IV, apply warm compress, monitor for progression to thrombophlebitis (fever, red streak up the arm, hard cord), and report immediately. Infection/bacteremia: caused by contamination at insertion, poor site care, or prolonged dwell. Prevention: use aseptic technique, change dressings if soiled, keep the site clean and dry, remove IVs promptly when no longer needed. Management: draw blood cultures, remove the IV, and start antibiotics if sepsis is suspected. Pneumothorax (if subclavian line placed): rare but life-threatening; presents as sudden chest pain and dyspnea; requires immediate chest X-ray and possible chest tube.
▶How do you maintain IV patency and prevent clots?
Flush the IV regularly (every 8–12 hours if not actively infusing, and after each medication or blood draw) with normal saline (saline-lock protocol). Use a 10-mL syringe to create turbulent flow, which breaks up clots better than a 3-mL syringe. Avoid using positive pressure (not 'pushing' flush too hard) which can damage the catheter. Observe the IV site for signs of a clot: difficulty flushing, inability to draw back blood, or swelling around the catheter. If a clot is forming or the IV is sluggish, try flushing gently, repositioning the arm, or removing the IV if unsuccessful. Never use a clot-dissolving drug to clear a peripheral IV without an order; this is done only for central lines in specialized settings. Remove the IV immediately if it has been in place >96 hours or if the patient no longer needs IV access; prolonged dwell time increases infection and thrombosis risk.
▶What is the difference between peripheral IV, central line (PICC), and tunneled central venous catheter?
Peripheral IV: short catheter (1.25 inches) in a peripheral vein (arm, hand, leg, scalp); used for short-term fluids, medications, and blood draws; maximum dwell 72–96 hours; easier to insert and lower infection risk but limited for viscous solutions and home use. PICC (Peripherally Inserted Central Catheter): long catheter (40–60 cm) inserted in an arm vein and advanced to the superior vena cava; used for intermediate-term therapy (weeks to months); can deliver vesicant drugs, TPN, and frequent blood draws; lower infection risk than peripheral but higher than central lines; requires imaging to confirm placement. Tunneled central line (Hickman, Groshong): catheter inserted surgically or via subclavian/jugular vein and tunneled under the skin; used for long-term therapy (months to years); lowest infection risk if well-maintained; requires surgical placement and removal. Each has different insertion risk, dwell time, and indication; use the least-invasive appropriate line.
▶How do you assess and document IV sites, and what does 'IV start assessment' include?
Assessment: inspect the IV site every hour during infusion and every shift if not infusing. Look for redness, swelling, warmth, drainage, or the catheter coming out of the skin. Palpate gently to feel for hardness (thrombophlebitis), tenderness, or fluid tracking under the skin (infiltration). Ask the patient about pain, burning, or discomfort at the site. Use the INS phlebitis scale: 0 = no symptoms, 1 = erythema at site (≤1 inch), 2 = erythema (>1 inch) and/or edema, 3 = erythema >1 inch, edema, warmth, and/or palpable cord (thrombophlebitis), 4 = all of the above plus fever or sepsis. IV start assessment includes: date and time of insertion, gauge and length of catheter, insertion site (e.g., 'right antecubital cephalic'), number of attempts (1st try success is best), type of fluid infusing, and patient tolerance. Document any complications and interventions (removed due to infiltration, redressed on day 2, etc.). Remove the IV if phlebitis score ≥3 or dwell time >96 hours.
▶What is the proper procedure for removing an IV and what precautions apply?
Gather supplies: sterile gauze, tape, and gloves. Explain to the patient that you are removing the IV and will apply pressure to prevent bleeding. Stop the infusion and disconnect the tubing. Don gloves and remove the dressing (peel carefully if the patient has fragile skin). Apply gentle pressure just above the catheter tip with sterile gauze, then slowly withdraw the catheter and tubing together in one smooth motion. Continue pressure for 1–2 minutes until bleeding stops. If the site was infected or the IV was in place >96 hours, consider culturing the catheter tip (send it in a sterile container to microbiology). Inspect the catheter for integrity (should come out intact; a broken piece left in the vein is rare but serious). Apply a small sterile dressing or band-aid and instruct the patient to keep the area clean and dry. Document the removal time, condition of the catheter, site appearance, and patient tolerance. Advise the patient to call if they notice redness, swelling, or drainage at the site after removal (sign of phlebitis or infection).
