Deck 28: Intravenous Therapy

Question 1

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

A) Check the IV access for patency.
B) Increase the infusion rate of the blood.
C) Discontinue the blood infusion.
D) Assess the patient for an ABO mismatch.

Answer 1

Discontinue the blood infusion.

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?

A) Instruct the patient how to protect the IV site.
B) Apply a new sterile dressing every day.
C) Change the IV tubing at least daily.
D) Flush the IV catheter every morning.

Answer 2

Instruct the patient how to protect the IV site.

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?

A) Avoid using soft, bouncy veins.
B) Choose the patient's best proximal vein.
C) Choose a site large enough for adequate blood flow.
D) Always use the smallest-gauge IV catheter available.

Answer 3

Choose a site large enough for adequate blood flow.

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?

A) Compare weight to baseline data.
B) Replace the infusion pump batteries.
C) Assess the patient for respiratory distress.
D) Reduce the infusion rate below 75 mL/hr.

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?

A) Use a site distal to the original site.
B) Place it wherever a vein is suitable.
C) Place the new site in a smaller vein.
D) Continue to use the nondominant extremity.

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?

A) Elevating the patient's arm to maintain the ordered flow
B) Padding the IV site for skin protection
C) Inspecting the insertion site on a regular schedule
D) Changing the site every day at the same time

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?

A) Expect minor pain at the insertion site.
B) Report redness at the insertion site.
C) Remain on bed rest with the IV infusion.
D) Disconnect IV tubing to change a gown.

Question 8

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

A) Determining patient history of autologous blood donations
B) Assessing patient baseline vital signs before the transfusion
C) Confirming the rate of the blood infusion with the health care provider
D) Identifying patient blood type, cross-match, and blood product

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?

A) 0.45 normal saline
B) 0.9 normal saline
C) D₅ 0.45 normal saline
D) Dextrose 5% in water

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?

A) Infuse a bolus of D₅NS to the patient now.
B) Regulate an IV infusion pump at 125 mL/hr.
C) Call the health care provider to clarify the order.
D) Perform venipuncture with a butterfly needle.

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?

A) Poor skin turgor
B) Bilateral crackles
C) Mild hypotension
D) High serum sodium

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?

A) Adjusting the infusion rate
B) Changing the IV dressing
C) Reporting patient complaints
D) Administering IV antibiotics

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?

A) Slow the infusion rate.
B) Discontinue the IV infusion.
C) Apply cool compresses.
D) Apply warm compresses.

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?

A) Instruct the patient to elevate his or her arm on two pillows.
B) Discontinue the IV infusion and start one in the right arm.
C) Apply a warm, moist compress to the IV site.
D) Reassess the IV site in 2 hours for any change.

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?

A) Flush with a low concentration of heparin.
B) Always change the end cap with each medication dose.
C) Change the IV insertion site every day.
D) Flush with 0.9% saline solution.

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?

A) Prepare a normal saline solution.
B) Obtain a Y-tubing for administration.
C) Provide the patient with information.
D) Identify the blood product and patient.

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?

A) Tell the patient that this is a common occurrence.
B) Stop the infusion and notify the health care provider.
C) Flush the tubing with normal saline solution.
D) Attach a 0.22-micrometer inline IV filter.

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?

A) Use clean technique for dressing changes.
B) Palpate the insertion site through the dressing.
C) Change the IV tubing at 12-hour intervals.
D) Routinely apply an antimicrobial to the IV site.

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?

A) Use a 3-mL syringe to flush.
B) Aspirate the IV line for a blood return.
C) Check for causes of resistance.
D) Inject the IV medication slowly.

Question 20

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

A) Slap the selected vein gently several times.
B) Select a proximal site on the extremity.
C) Shave the hair in the area of the insertion site.
D) Tie a tourniquet above the selected insertion site.

Question 21

A patient on an anticoagulant is going home and needs the peripheral IV line removed.Which action is essential for the nurse to take?

A) Pull the IV catheter out smoothly but quickly.
B) Apply sterile gloves before going to the patient's bedside.
C) Check the most recent clotting studies.
D) Apply pressure over the insertion site for 5-10 minutes.

Question 22

The nurse is caring for a patient with a peripheral IV line and needs to change the dressing.What action by the nurse prevents accidental dislodgement of the IV catheter?

A) Stabilize the IV catheter until the tape is in place.
B) Place folded gauze under the IV catheter hub.
C) Wear clean gloves to remove the old dressing.
D) Clean in a circular motion away from the site.

Question 23

A patient has IV fluids prescribed at 40 mL/hr through microdrip tubing.Which rate does the nurse use to infuse the patient's IV fluid? _____ gtts/min.

Question 24

The prescription for the patient's IV fluid reads, "Infuse 1000 mL over 10 hours." At which rate does the nurse infuse the IV fluids using IV tubing with a drop factor of 15 gtts/mL? _____gtts/min.

Question 25

The nurse is preparing to change the IV solution after the current one infuses.What action is most appropriate for the nurse to take?

A) Hang another bag of the identical IV solution.
B) Change the tubing when preparing a new IV bag.
C) Allow IV fluid to empty into the upper part of the tubing.
D) Change the bag when approximately 50 mL is left in the old bag.

Question 26

The nurse observes bleeding on the dressing of a site where the IV was discontinued.Which action should the nurse take first?

A) Hold pressure on the site.
B) Replace the dressing.
C) Apply a warm compress.
D) Lower the site below the level of the heart.

Question 27

The health care provider prescribes 500 mL of 0.25% normal saline intravenously over 4 hours for the patient.At which rate does the nurse infuse the IV solution into the patient using IV tubing with a drop factor of 15 gtts/mL? _____ gtts/min.

Question 28

The order calls for the patient to receive 500 mL of IV fluid over 4 hours, and the nurse uses IV tubing with a drop factor at 10 gtts/mL.Which rate should the nurse use on an electronic infusion pump for IV fluids to administer this prescription? ________ mL/hr.

Question 29

A patient in the emergency department needs a blood transfusion of A^- blood, and none is available.Nursing care would be correct if the nurse administered blood of which type?

A) A+
B) O+
C) O^-
D) AB^-

Question 30

The nurse is preparing to initiate a blood transfusion.Which step of the procedure does the nurse implement first?

A) Begin the infusion at 2 mL/min.
B) Establish a single-line infusion.
C) Check vital signs in 30 minutes.
D) Shake the blood gently to mix the preservative.

Question 31

The nurse is administering an IV infusion via a central venous access device.Which outcome would best substantiate the nurse's assessment that the patient has not experienced a complication?

A) The patient gains 2 1/2 pounds in 2 days.
B) The patient's insertion site is warm and dry.
C) The patient has subcutaneous emphysema.
D) The patient's neck veins are less distended today than yesterday.

Question 32

The nurse assesses the patient's IV site.Which clinical indicator does the nurse recognize as being most consistent with phlebitis?

A) An elevated heart rate
B) Decreased skin temperature
C) Erythema along the vein line
D) Edema around the insertion site

Question 33

The nurse administers blood to the patient and observes that the patient has tachycardia, chills, and lower back pain.What action does the nurse take first?

A) Notify the health care provider.
B) Notify the blood bank.
C) Complete the vital signs.
D) Remove the IV tubing.