INTRAVENOUS THERAPY- SAUNDERS
NCLEX REVIEW EXAM QUESTIONS &
ANSWERS PASSED ALREADY
GRADED A+
A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The
nurse making rounds at 1545 finds that the client is complaining of a pounding
headache and is dyspneic, experiencing chills, and apprehensive, with an increased
pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take
which action first?
1. Slow the IV infusion.
2. Sit the client up in bed.
3. Remove the IV catheter.
4. Call the health care provider (HCP). - Correct Answer ✔✔ 1
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.
The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in
water with 20 mEq of potassium chloride. The nurse also needs to hang an IV infusion
of piperacillin/tazobactam. The client has one IV site. The nurse should plan to take
which action first?
1. Start a second IV site.
2. Check compatibility of the medication and IV fluids.
3. Mix the prepackaged piperacillin/tazobactam per agency policy.
4. Prime the tubing with the IV solution, and back-prime the medication. - Correct
Answer ✔✔ 2
Rationale: When hanging an IV antibiotic, the nurse should first check compatibility of
the medication and the IV fluids currently prescribed. If the fluids and medication are
incom- patible, it would then be appropriate to start a second IV site. If they are
compatible, the nurse should hang them together so as to avoid having to start another
IVsite. After this, the nurse should prepare the prepackaged piperacillin/tazobactam per
agency policy, then prime the tubing with the IV solution, and then back-prime the
, medication. Back-priming prevents any medication from being lost during the priming
process.
The nurse is completing a time tape for a 1000-mL intravenous (IV) bag that is
scheduled to infuse over 8 hours. The nurse has just placed the 1100 marking at the
500-mL level. The nurse would place the mark for 1200 at which numerical level (mL)
on the time tape? Fill in the blank.
Answer: ______ mL - Correct Answer ✔✔ 375
Rationale: If the IV is scheduled to run over 8 hours, the hourly rate is 125mL/hour.
Using 500mL as the reference point, the next hourly marking would be at 375 mL, which
is 125 mL less than 500.
The nurse is making initial rounds on the nursing unit to assess the condition of
assigned clients. Which assessment findings are consistent with infiltration? Select all
that apply.
1. Pain and erythema
2. Pallor and coolness
3. Numbness and pain
4. Edema and blanched skin
5. Formation of a red streak and purulent drainage - Correct Answer ✔✔ 2,3,4
Rationale: An infiltrated intravenous (IV) line is one that has dislodged from the vein and
is lying in subcutaneous tissue. Pallor, coolness, edema, pain, numbness, and blanched
skin are the results of IVfluid being deposited in the subcutaneous tissue. When the
pressure in the tissues exceeds the pressure in the tubing, the flow of the IVsolution will
stop, and if an elec- tronic pump is being used, it will alarm. Erythema can be asso-
ciated with infection, phlebitis, or thrombosis. Formation of a red streak and purulent
drainage is associated with phlebitis and infection.
The nurse is inserting an intravenous (IV) line into a client's vein. After the initial stick,
the nurse would continue to advance the catheter in which situation?
1. The catheter advances easily.
2. The vein is distended under the needle.
3. The client does not complain of discomfort.
4. Blood return shows in the backflash chamber of the catheter. - Correct Answer ✔✔ 4
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, and if further distention occurs after
venipuncture, this could mean the needle went through the vein and into the tissue;
therefore, the catheter should not be advanced. Client discomfort varies with the client,
the site, and the nurse's insertion technique and is not a reliable measure of catheter
NCLEX REVIEW EXAM QUESTIONS &
ANSWERS PASSED ALREADY
GRADED A+
A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The
nurse making rounds at 1545 finds that the client is complaining of a pounding
headache and is dyspneic, experiencing chills, and apprehensive, with an increased
pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take
which action first?
1. Slow the IV infusion.
2. Sit the client up in bed.
3. Remove the IV catheter.
4. Call the health care provider (HCP). - Correct Answer ✔✔ 1
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.
The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in
water with 20 mEq of potassium chloride. The nurse also needs to hang an IV infusion
of piperacillin/tazobactam. The client has one IV site. The nurse should plan to take
which action first?
1. Start a second IV site.
2. Check compatibility of the medication and IV fluids.
3. Mix the prepackaged piperacillin/tazobactam per agency policy.
4. Prime the tubing with the IV solution, and back-prime the medication. - Correct
Answer ✔✔ 2
Rationale: When hanging an IV antibiotic, the nurse should first check compatibility of
the medication and the IV fluids currently prescribed. If the fluids and medication are
incom- patible, it would then be appropriate to start a second IV site. If they are
compatible, the nurse should hang them together so as to avoid having to start another
IVsite. After this, the nurse should prepare the prepackaged piperacillin/tazobactam per
agency policy, then prime the tubing with the IV solution, and then back-prime the
, medication. Back-priming prevents any medication from being lost during the priming
process.
The nurse is completing a time tape for a 1000-mL intravenous (IV) bag that is
scheduled to infuse over 8 hours. The nurse has just placed the 1100 marking at the
500-mL level. The nurse would place the mark for 1200 at which numerical level (mL)
on the time tape? Fill in the blank.
Answer: ______ mL - Correct Answer ✔✔ 375
Rationale: If the IV is scheduled to run over 8 hours, the hourly rate is 125mL/hour.
Using 500mL as the reference point, the next hourly marking would be at 375 mL, which
is 125 mL less than 500.
The nurse is making initial rounds on the nursing unit to assess the condition of
assigned clients. Which assessment findings are consistent with infiltration? Select all
that apply.
1. Pain and erythema
2. Pallor and coolness
3. Numbness and pain
4. Edema and blanched skin
5. Formation of a red streak and purulent drainage - Correct Answer ✔✔ 2,3,4
Rationale: An infiltrated intravenous (IV) line is one that has dislodged from the vein and
is lying in subcutaneous tissue. Pallor, coolness, edema, pain, numbness, and blanched
skin are the results of IVfluid being deposited in the subcutaneous tissue. When the
pressure in the tissues exceeds the pressure in the tubing, the flow of the IVsolution will
stop, and if an elec- tronic pump is being used, it will alarm. Erythema can be asso-
ciated with infection, phlebitis, or thrombosis. Formation of a red streak and purulent
drainage is associated with phlebitis and infection.
The nurse is inserting an intravenous (IV) line into a client's vein. After the initial stick,
the nurse would continue to advance the catheter in which situation?
1. The catheter advances easily.
2. The vein is distended under the needle.
3. The client does not complain of discomfort.
4. Blood return shows in the backflash chamber of the catheter. - Correct Answer ✔✔ 4
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, and if further distention occurs after
venipuncture, this could mean the needle went through the vein and into the tissue;
therefore, the catheter should not be advanced. Client discomfort varies with the client,
the site, and the nurse's insertion technique and is not a reliable measure of catheter
