IV Therapy Practice questions
IV Therapy Practice questions for all types of Medical exams. specially prepared for the NCLEX exam. go with these quiz with confidence . Good Luck,
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IV Therapy Practice Questions.
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- Question 1 of 11
1. Question
A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 3 PM. The nurse making rounds at 3:45 PM finds that the client is complaining of a pounding headache and is dyspneic, is experiencing chills, and is apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first?
CorrectAnswer & Rationale.
Option 1 is correct answer.
Rationale: The client’s symptoms are compatible with circulatory overload. This may be verified by noting that 600 mL has infused in the course of 45 minutes. The first action of the nurse is to slow the infusion. Other actions may follow in rapid sequence. The nurse may elevate the head of the bed to aid the client’s breathing, if necessary. The nurse also notifies the HCP. The IV catheter is not removed; it may be needed for the administration of medications to resolve the complication.
IncorrectAnswer & Rationale.
Option 1 is correct answer.
Rationale: The client’s symptoms are compatible with circulatory overload. This may be verified by noting that 600 mL has infused in the course of 45 minutes. The first action of the nurse is to slow the infusion. Other actions may follow in rapid sequence. The nurse may elevate the head of the bed to aid the client’s breathing, if necessary. The nurse also notifies the HCP. The IV catheter is not removed; it may be needed for the administration of medications to resolve the complication.
- Question 2 of 11
2. Question
The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride and needs to add the medication to the IV bag. The nurse should plan to take which action immediately after injecting the potassium chloride into the port of the IV bag?
CorrectAnswer & Rationale.
Option 1 is correct answer.
Rationale: After adding a medication to a bag of IV solution, the nurse should agitate or rotate the bag gently to mix the medication evenly in the solution. The nurse should then attach a completed medication label. The nurse can then prime the tubing. The IV solution should have been checked for discoloration before the medication was added to the solution. The tubing is attached to the client last.
IncorrectAnswer & Rationale.
Option 1 is correct answer.
Rationale: After adding a medication to a bag of IV solution, the nurse should agitate or rotate the bag gently to mix the medication evenly in the solution. The nurse should then attach a completed medication label. The nurse can then prime the tubing. The IV solution should have been checked for discoloration before the medication was added to the solution. The tubing is attached to the client last.
- Question 3 of 11
3. Question
The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client’s intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which complication has occurred?
CorrectAnswer & Rationale.
Option 3 is correct answer.
Rationale: An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling are the results of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and start a new IV line at another site. Infection, phlebitis, and thrombosis are likely to be accompanied by warmth at the site, not coolness.
IncorrectAnswer & Rationale.
Option 3 is correct answer.
Rationale: An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling are the results of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and start a new IV line at another site. Infection, phlebitis, and thrombosis are likely to be accompanied by warmth at the site, not coolness.
- Question 4 of 11
4. Question
The nurse is inserting an intravenous line into a client’s vein. After the initial stick, the nurse would continue to advance the catheter in which situation?
CorrectAnswer & Rationale.
Option 4 is correct answer.
Rationale: The IV catheter has entered the lumen of the vein successfully when blood backflash shows in the IV catheter. The vein should have been distended by the tourniquet before the vein was cannulated. Client discomfort varies with the client, the site, and the nurse’s insertion technique and is not a reliable measure of catheter placement. The nurse should not advance the catheter until placement in the vein is verified by blood return.
IncorrectAnswer & Rationale.
Option 4 is correct answer.
Rationale: The IV catheter has entered the lumen of the vein successfully when blood backflash shows in the IV catheter. The vein should have been distended by the tourniquet before the vein was cannulated. Client discomfort varies with the client, the site, and the nurse’s insertion technique and is not a reliable measure of catheter placement. The nurse should not advance the catheter until placement in the vein is verified by blood return.
- Question 5 of 11
5. Question
The nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse should document in the medical record that the client experienced which condition?
CorrectAnswer & Rationale.
Option 1 is correct answer.
Rationale: Phlebitis at an IV site can be distinguished by client discomfort at the site and by redness, warmth, and swelling proximal to the catheter. If phlebitis occurs, the nurse should discontinue the IV line and insert a new IV line at a different site. Coolness at the site would be noted if the IV catheter was infiltrated. An allergic reaction produces a rash, redness, and itching. A major reaction, such as hypersensitivity, can cause dyspnea, a swollen tongue, and cyanosis.
IncorrectAnswer & Rationale.
Option 1 is correct answer.
Rationale: Phlebitis at an IV site can be distinguished by client discomfort at the site and by redness, warmth, and swelling proximal to the catheter. If phlebitis occurs, the nurse should discontinue the IV line and insert a new IV line at a different site. Coolness at the site would be noted if the IV catheter was infiltrated. An allergic reaction produces a rash, redness, and itching. A major reaction, such as hypersensitivity, can cause dyspnea, a swollen tongue, and cyanosis.
- Question 6 of 11
6. Question
The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action?
CorrectAnswer & Rationale.
Option 2 is correct answer.
Rationale: The nurse should obtain new IV tubing because contamination has occurred and could cause systemic infection to the client. There is no need to obtain a new IV bag because the bag was not contaminated. Wiping with Betadine or alcohol is insufficient and is contraindicated because the spike will be inserted into the IV bag.
IncorrectAnswer & Rationale.
Option 2 is correct answer.
Rationale: The nurse should obtain new IV tubing because contamination has occurred and could cause systemic infection to the client. There is no need to obtain a new IV bag because the bag was not contaminated. Wiping with Betadine or alcohol is insufficient and is contraindicated because the spike will be inserted into the IV bag.
- Question 7 of 11
7. Question
A health care provider has written a prescription to discontinue an intravenous (IV) line. The nurse should obtain which item from the unit supply area for applying pressure to the site after removing the IV catheter?
CorrectAnswer & Rationale.
Option 4 is correct answer.
Rationale: A dry sterile dressing such as a sterile 2 × 2 is used to apply pressure to the discontinued IV site. This material is absorbent, sterile, and nonirritating. A Betadine swab would irritate the opened puncture site and would not stop the blood flow. An adhesive bandage or elastic wrap may be used to cover the site once hemostasis has occurred.
IncorrectAnswer & Rationale.
Option 4 is correct answer.
Rationale: A dry sterile dressing such as a sterile 2 × 2 is used to apply pressure to the discontinued IV site. This material is absorbent, sterile, and nonirritating. A Betadine swab would irritate the opened puncture site and would not stop the blood flow. An adhesive bandage or elastic wrap may be used to cover the site once hemostasis has occurred.
- Question 8 of 11
8. Question
A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which action(s) in the care of this client? Select all that apply.
CorrectAnswer & Rationale.
Options 1,2,3,5 are correct answers.
Rationale: Phlebitis is an inflammation of the vein that can occur from mechanical or chemical (medication) trauma or from a local infection and can cause the development of a clot (thrombophlebitis). The nurse should remove the IV at the phlebitic site and apply warm moist compresses to the area to speed resolution of the inflammation. Because phlebitis has occurred, the nurse also notifies the HCP about the IV complication. The nurse should restart the IV in a vein other than the one that has developed phlebitis. Finally, the nurse documents the occurrence, actions taken, and the client’s response.
Rationale: Phlebitis is an inflammation of the vein that can occur from mechanical or chemical (medication) trauma or from a local infection and can cause the development of a clot (thrombophlebitis). The nurse should remove the IV at the phlebitic site and apply warm moist compresses to the area to speed resolution of the inflammation. Because phlebitis has occurred, the nurse also notifies the HCP about the IV complication. The nurse should restart the IV in a vein other than the one that has developed phlebitis. Finally, the nurse documents the occurrence, actions taken, and the client’s response.
IncorrectAnswer & Rationale.
Options 1,2,3,5 are correct answers.
Rationale: Phlebitis is an inflammation of the vein that can occur from mechanical or chemical (medication) trauma or from a local infection and can cause the development of a clot (thrombophlebitis). The nurse should remove the IV at the phlebitic site and apply warm moist compresses to the area to speed resolution of the inflammation. Because phlebitis has occurred, the nurse also notifies the HCP about the IV complication. The nurse should restart the IV in a vein other than the one that has developed phlebitis. Finally, the nurse documents the occurrence, actions taken, and the client’s response.
Rationale: Phlebitis is an inflammation of the vein that can occur from mechanical or chemical (medication) trauma or from a local infection and can cause the development of a clot (thrombophlebitis). The nurse should remove the IV at the phlebitic site and apply warm moist compresses to the area to speed resolution of the inflammation. Because phlebitis has occurred, the nurse also notifies the HCP about the IV complication. The nurse should restart the IV in a vein other than the one that has developed phlebitis. Finally, the nurse documents the occurrence, actions taken, and the client’s response.
- Question 9 of 11
9. Question
A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will most likely be prescribed to increase intravascular volume, replace immediate blood loss volume, and increase blood pressure?
CorrectAnswer & Rationale.
Option 1 is correct answer.
Rationale: The goal of therapy with this client is to expand intravascular volume as quickly as possible. The 5% dextrose in lactated Ringer’s (hypertonic solution) would increase intravascular volume and immediately replace lost fluid volume until a transfusion could be administered, resulting in an increase in the client’s blood pressure. The solutions in the remaining options would not be given to this client because they are hypotonic solutions and, instead of increasing intravascular space, the solutions would move into the cells via osmosis.
IncorrectAnswer & Rationale.
Option 1 is correct answer.
Rationale: The goal of therapy with this client is to expand intravascular volume as quickly as possible. The 5% dextrose in lactated Ringer’s (hypertonic solution) would increase intravascular volume and immediately replace lost fluid volume until a transfusion could be administered, resulting in an increase in the client’s blood pressure. The solutions in the remaining options would not be given to this client because they are hypotonic solutions and, instead of increasing intravascular space, the solutions would move into the cells via osmosis.
- Question 10 of 11
10. Question
The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instructions if the client made which statement?
CorrectAnswer & Rationale.
Option 2 is correct answer.
Rationale: The client should be taught that only minor activity restrictions apply with this type of catheter. The client should protect the site during bathing and should carry or wear a Medic-Alert identification. The client should have a repair kit in the home for use as needed because the catheter is for long-term use.
IncorrectAnswer & Rationale.
Option 2 is correct answer.
Rationale: The client should be taught that only minor activity restrictions apply with this type of catheter. The client should protect the site during bathing and should carry or wear a Medic-Alert identification. The client should have a repair kit in the home for use as needed because the catheter is for long-term use.
- Question 11 of 11
11. Question
A client has just undergone insertion of a central venous catheter at the bedside. The nurse would be sure to check which results before initiating the flow rate of the client’s intravenous (IV) solution at 100 mL/hour?
CorrectAnswer & Rationale.
Option 3 is correct answer.
Rationale: Before beginning administration of IV solution, the nurse should assess whether the chest radiograph reveals that the central catheter is in the proper place. This is necessary to prevent infusion of IV fluid into pulmonary or subcutaneous tissues. The other options represent items that are useful for the nurse to be aware of in the general care of this client, but they do not relate to this procedure.
IncorrectAnswer & Rationale.
Option 3 is correct answer.
Rationale: Before beginning administration of IV solution, the nurse should assess whether the chest radiograph reveals that the central catheter is in the proper place. This is necessary to prevent infusion of IV fluid into pulmonary or subcutaneous tissues. The other options represent items that are useful for the nurse to be aware of in the general care of this client, but they do not relate to this procedure.
Intravenous Therapy: Purpose and uses
- Provides immediate access to the vascular system for the rapid delivery of specific solutions without the time required for gastrointestinal tract absorption
- Replaces water, electrolytes, and nutrients more rapidly than oral administration
- Used to sustain clients who are unable to take substances orally
- Purpose and uses
- Provides a vascular route for the administration of medication or blood components