Deck 36: Administering Intravenous Solutions and Medications

Question 1

The nurse observes that the insertion site of an IV catheter looks pale and puffy and the area feels cool to the touch. The initial action for the nurse should be to:

A) discontinue the infusion and start a new IV site.
B) apply warm compresses to the site.
C) monitor the patient's temperature every 4 hours.
D) call the primary care provider and report these findings.

Answer 1

discontinue the infusion and start a new IV site.

Question 2

When a patient receiving IV medication exhibits light headedness, tightness in the chest, flushed face, and irregular pulse, the nurse suspects:

A) speed shock.
B) drug allergy.
C) fluid overload.
D) air embolus.

Answer 2

speed shock.

Question 3

The nurse takes into consideration that according to The Joint Commission, the first IV antibiotics order for a community acquired pneumonia must be administered within:

A) 2 hours.
B) 4 hours.
C) 6 hours.
D) 24 hours.

Answer 3

4 hours.

Question 4

The nurse evaluating a piggyback IV setup finds an error in the construction of the fluids. Which situation would the nurse correct?

A) Secondary bag is hung higher than the primary bag.
B) Primary line clamp is closed.
C) Slide clamp near the insertion site is open.
D) Secondary line clamp is open.

Question 5

A nurse is monitoring the status of an older adult patient who is receiving IV therapy. Indicator of fluid volume overload is suspected when the nurse assesses:

A) crackles in the lung fields.
B) pulse rate of 64 beats/min, irregular.
C) respirations of 16 breaths/min, regular.
D) slight edema to the feet.

Question 6

To facilitate the administration of an IV antibiotic every 6 hours to a patient who is ambulatory, well hydrated, and on a regular diet, the nurse would insert a(n):

A) primary IV line.
B) secondary IV line.
C) intermittent infusion device.
D) central venous line.

Question 7

A patient has just undergone placement of a central venous catheter through the subclavian vein. When the placement is complete, the nurse should:

A) hang the prescribed fluid at a rate of 1 mL/min.
B) assess the quality of the breath sounds.
C) note the length of the tubing.
D) wait for the results of the chest radiograph before beginning fluids.

Question 8

The nurse anticipates that the malnourished postoperative 70-year-old patient will receive an intravenous (IV) infusion of 5% dextrose in 0.45% saline, because it is:

A) isotonic.
B) hypotonic.
C) hypertonic.
D) total parenteral nutrition.

Question 9

The nurse assisting in the initiation of a blood transfusion is aware that the only appropriate solution to infuse through a parallel infusion set before and after the transfusion is:

A) 5% dextrose in water.
B) 10% dextrose in water.
C) lactated Ringer's solution.
D) normal saline.

Question 10

A patient receiving TPN fluid therapy experiences an air embolus in the central line. The nurse should immediately turn the patient onto the:

A) right side and raise the head of the bed.
B) right side and lower the head of the bed.
C) left side and raise the head of the bed.
D) left side and lower the head of the bed.

Question 11

A nurse accessing the injection port of the IV tubing will "scrub the hub" for:

A) 5 seconds.
B) 10 seconds.
C) 15 seconds.
D) 30 seconds.

Question 12

A patient has an order for an infusion of 5% dextrose in 0.45% sodium chloride at a rate of 100 mL/hr IV. The IV tubing has a drop factor of 15 gtt/mL. At how many drops per minute should the nurse regulate the infusion?

A) 15
B) 17
C) 25
D) 33

Question 13

The nurse is aware that as a safety precaution against over hydration, the tubing drip factor set appropriate for a 6-month-old infant is:

A) 60 gtt/mL.
B) 20 gtt/mL.
C) 15 gtt/mL.
D) 10 gtt/mL.

Question 14

A patient is to have an IV insertion site changed. The current line is in the lower right forearm. Which location is contraindicated for the new site?

A) Right upper forearm
B) Right hand
C) Left upper forearm
D) Left hand

Question 15

The nurse would plan to get another nurse to try to obtain a successful venipuncture if the first nurse was not successful in:

A) five attempts.
B) three attempts.
C) two attempts.
D) one attempt.

Question 16

A patient is receiving IV fluids through an infusion pump. How often should the nurse check the functioning of the pump?

A) Every 15 to 30 minutes
B) Every 1 to 2 hours
C) Every 2 to 4 hours
D) Once during the shift

Question 17

A nurse is aware that for a patient with a continuous IV infusion running, the IV bag should be changed when only ______ mL of solution remains in the bag.

A) 10 mL
B) 25 mL
C) 50 mL
D) 100 mL

Question 18

A patient is admitted with a peripherally inserted central catheter (PICC). As part of standard care for this patient, the nurse should:

A) obtain the patient's temperature every 2 hours.
B) prepare to infuse fluids at high volumes.
C) avoid taking blood pressures on the arm with the PICC line.
D) have the catheter withdrawn while the patient is hospitalized.

Question 19

The nurse is planning for the initiation of a blood transfusion. The type of tubing the nurse will prepare is a:

A) piggyback set.
B) primary infusion set.
C) controlled volume set.
D) Y administration set.

Question 20

A patient rings the call bell and states that the IV insertion site is painful. The site is reddened, warm, and swollen. The nurse assesses that the patient is most likely experiencing:

A) bloodstream infection.
B) catheter embolus.
C) infiltration of the line.
D) phlebitis.

Question 21

The nurse is aware that the disadvantages of infusion pumps include: (Select all that apply.)

A) a saline lock is required.
B) infusion pump change out every shift.
C) the initial expense of machines.
D) an alarm that can be deactivated by family.
E) the need for special administration sets.

Question 22

A patient complains of chills, back pain, and shortness of breath a few minutes after the blood infusion is started. The first thing the nurse should do is:

A) slow down the blood infusion.
B) stop the blood infusion and start the saline.
C) monitor vital signs and call the primary care provider.
D) start low flow oxygen as per facility protocol.

Question 23

Signs that would cause the nurse to discontinue a blood transfusion would include: (Select all that apply.)

A) hives.
B) facial flushing.
C) nosebleed.
D) back pain.
E) bloody colored urine.

Question 24

A patient who requires an immediate transfusion of blood has previously signed a consent form to receive it. The nurse confirms that the consent was signed within the last:

A) 8 hours.
B) 12 hours.
C) 24 hours.
D) 48 to 72 hours.

Question 25

The LVN/LPN is told by the RN to discontinue an IV line to the patient. The best nursing action is to:

A) check the primary care provider's order.
B) stop the IV flow by clamping the tubing securely.
C) wash hands and don gloves.
D) quickly withdraw the cannula and apply pressure.

Question 26

Place the steps in order for the preparation to initiate a blood line: (Separate letters by a comma and space as follows: A, B, C, D, E.)

A) Compare patient name, ID number on wrist bank with transfusion record.
B) Obtain Y connector setup and saline and prime the filter with saline.
C) Clamp off saline and start blood.
D) Confirm the presence of a permission slip.
E) Obtain baseline vital signs.

Question 27

The nurse instills diluted medication in the portion of the controlled volume IV setup, which is called the ___________.

Question 28

A patient has an IV of 1000 mL 5% dextrose in 1/2 normal saline (0.45% sodium chloride) infusing via microdrip for 12 hours. The IV is infusing ________ gtt/min.

Question 29

The primary care provider orders an IV of 5% dextrose in normal saline (0.45% sodium chloride) to infuse over a 10-hour period. Which of the following actions should the nurse take? (Select all that apply.)

A) Monitor intake and output (I&O) every shift.
B) Monitor weight daily.
C) Flush with heparin solution intermittently.
D) Monitor lung sounds every 4 hours.
E) Monitor IV site for infiltration.
F) Monitor blood sugar levels.

Question 30

After the blood infusion has started, the nurse should let the blood flow at 2 mL/min for the first ___________ minutes.

Question 31

The nurse caring for a patient with an intermittent IV device should:

A) attach continuous fluid infusion to the device.
B) infuse saline or heparin solution to maintain patency.
C) discontinue when the IV medication is finished.
D) reduce patient activity to prevent dislodgement.