Question 1

The nurse infuses a unit of blood, but after 4 hours the blood infusion is not complete.Which action is most appropriate?

Accepted Answer

Blood transfusions should be completed within 4 hours to prevent bacterial growth and reduce the risk of infection. Discontinuing the infusion is the safest action.

Question 2

The patient has an intermittent infusion device inserted in the hand.Which strategy does the nurse use to prevent the IV catheter from being dislodged?

Accepted Answer

Instructing the patient on how to protect the IV site helps prevent accidental dislodgement by making the patient aware of movements or actions that could compromise the catheter's position.

Question 3

The nurse is trying to access the best insertion site on a patient for IV therapy.Which principle would the nurse use to achieve this goal?

Accepted Answer

Choosing a site large enough for adequate blood flow ensures that the vein can accommodate the IV catheter and maintain proper circulation, reducing the risk of complications.

Question 4

The prescription for the patient's IV infusion reads, "100 mL/hr." The nurse observes that the patient's IV line infused 125 mL in addition to the ordered volume after 2 hours.Which is the most important intervention for the nurse to implement?

Accepted Answer

The nurse should assess the patient for respiratory distress because the excess fluid infused could lead to fluid overload, which can cause respiratory complications.

Question 5

The nurse prepares to relocate an IV catheter because of signs of infiltration.The IV was located in the patient's nondominant hand.Which criterion would be best for the nurse to use when deciding on the location of the new IV site?

Accepted Answer

The answer of The nurse prepares to relocate an IV...

Question 6

The nurse is caring for several patients who have IV lines.What responsibility does the nurse have related to the assessment and maintenance of a peripheral IV site?

Accepted Answer

The nurse is responsible for regularly inspecting the IV insertion site to monitor for signs of infection, infiltration, or other complications.

Question 7

After inserting a peripheral IV line into the patient, the nurse provides patient teaching about the IV insertion site.What information does the nurse give to the patient?

Accepted Answer

The nurse instructs the patient to report redness at the insertion site as it may indicate infection or inflammation.

Question 8

The nurse prepares to administer blood to the patient.Which is the nurse's priority action?

Accepted Answer

The priority action is to ensure the correct blood type and product are matched to the patient to prevent transfusion reactions.

Question 9

The nurse is preparing to administer blood.What solution is most appropriate for the nurse to use when priming the blood administration set?

Accepted Answer

The answer of The nurse is preparing to administer blood.What...

Question 10

The health care provider's order reads, "Administer 5% dextrose solution with normal saline (D₅NS) intravenously now." What action does the nurse perform first?

Accepted Answer

The nurse should first clarify the order with the health care provider to ensure the correct rate and volume of infusion, as the order lacks specific details.

Question 11

The nurse assesses several patients who are receiving IV therapy.Which clinical indicator cues the nurse to take special precautions while infusing IV fluids on one of the patients?

Accepted Answer

Bilateral crackles may indicate fluid overload or pulmonary edema, requiring careful monitoring and possibly slower infusion rates to prevent exacerbating the condition.

Question 12

The nurse is explaining to nursing assistive personnel (NAP) how to help maintain the patient's IV therapy.What action regarding IV therapy can be delegated to the NAP?

Accepted Answer

NAP can report patient complaints to the nurse, but they are not authorized to adjust infusion rates, change IV dressings, or administer medications.

Question 13

The nurse assesses the patient's IV insertion site and notes that it is warm, red, and tender.Which intervention does the nurse implement first?

Accepted Answer

The symptoms described suggest phlebitis or infection at the IV site. The first step is to discontinue the IV infusion to prevent further complications.

Question 14

The nurse observes that the patient's left cephalic IV site is cool, swollen, and mildly tender, although the IV line is infusing at the prescribed rate.Which action does the nurse take first?

Accepted Answer

The symptoms indicate infiltration, so the nurse should discontinue the IV infusion to prevent further complications and start a new IV line in a different location.

Question 15

The nurse is caring for a patient with a peripheral IV access that is used intermittently for medications but is not a continuous infusion.Which technique does the nurse use for routine care of this peripheral line?

Accepted Answer

Flushing with 0.9% saline solution is the standard practice for maintaining patency of a peripheral IV line that is used intermittently.

Question 16

The nurse is setting up to administer a unit of blood.Which is the most important nursing intervention during preparation for this procedure?

Accepted Answer

Identifying the blood product and patient is crucial to ensure the correct blood type is administered to the correct patient, preventing potentially life-threatening transfusion reactions.

Question 17

The nurse observes fine white crystals in the IV tubing that is infusing an antibiotic.Which action by the nurse is most appropriate?

Accepted Answer

The presence of fine white crystals in the IV tubing indicates a potential precipitation of the medication, which can be harmful if infused into the patient. The nurse should stop the infusion immediately and notify the healthcare provider to prevent any adverse effects.

Question 18

The patient has a peripheral infusion for the administration of antibiotics.Which action is most effective for the nurse to use to detect an IV therapy-related infection?

Accepted Answer

Palpating the insertion site through the dressing allows the nurse to assess for tenderness, warmth, or swelling, which are signs of infection.

Question 19

The nurse feels resistance while trying to flush the IV line with a 5-mL syringe of normal saline solution before administering a medication by IV bolus.Which action does the nurse implement next?

Accepted Answer

The nurse should first check for causes of resistance to ensure there is no blockage or complication with the IV line before proceeding with any further actions.

Question 20

The nurse is preparing to insert a peripheral IV line.Which technique does the nurse implement to prepare for the IV insertion?

Accepted Answer

Tying a tourniquet above the selected insertion site helps to engorge the vein, making it more visible and easier to access for IV insertion.

Quiz 28: Intravenous Therapy