PNR 202/PNR202 Exam 4 V1 | Intravenous
Therapy Q&A with Rationale | Fortis
College
1. A nurse is preparing to administer an isotonic intravenous solution to a patient with fluid
volume deficit. Which of the following solutions should the nurse select?
A. 0.45% Sodium Chloride
B. 10% Dextrose in Water
C. 3% Sodium Chloride
D. 0.9% Sodium Chloride
Correct Answer: D
Expert Explanation: 0.9% Sodium Chloride is considered an isotonic solution because its
osmolarity is similar to that of blood plasma. It expands the extracellular fluid volume
without causing a fluid shift between the intracellular and extracellular compartments.
This makes it the primary choice for initial volume replacement in patients with
dehydration or hypotension.
2. Upon assessment of an IV site, the nurse notes coolness of the skin, edema, and a
significant decrease in the flow rate. Which complication does the nurse suspect?
A. Infiltration
B. Phlebitis
,C. Extravasation
D. Thrombophlebitis
Correct Answer: A
Expert Explanation: Infiltration occurs when a non-vesicant IV solution leaks into the
surrounding subcutaneous tissue. The hallmark signs include local edema, coolness of the
skin near the site, and blanching of the skin. The nurse should immediately stop the
infusion and remove the catheter to prevent further tissue damage.
3. A patient receiving intravenous therapy suddenly develops respiratory distress, chest pain,
and a loud churning sound is heard over the precordium. What is the priority nursing action?
A. Place the patient in the left Trendelenburg position.
B. Place the patient in the high-Fowler’s position.
C. Slow the infusion to a keep-vein-open (KVO) rate.
D. Administer a bolus of 500 mL normal saline.
Correct Answer: A
Expert Explanation: These symptoms are classic indicators of an air embolism, which is a
life-threatening complication of IV therapy. Placing the patient in the left Trendelenburg
position helps trap the air in the apex of the right ventricle, preventing it from entering the
pulmonary artery. The nurse must also notify the healthcare provider immediately and
provide supplemental oxygen.
, 4. The nurse is monitoring a patient receiving a hypertonic IV solution. For which of the
following complications should the nurse be most vigilant?
A. Cerebral edema
B. Fluid volume deficit
C. Hypotension
D. Circulatory overload
Correct Answer: D
Expert Explanation: Hypertonic solutions have a higher osmolarity than plasma, causing
water to be pulled from the intracellular space into the vascular space. This rapid
expansion of blood volume increases the risk of circulatory overload and pulmonary
edema. Nurses must monitor heart sounds, breath sounds, and blood pressure closely
during administration.
5. Which of the following instructions should the nurse provide to a patient who is about to
receive a peripheral IV catheter insertion?
A. ‘You will need to keep your arm perfectly still for the next 24 hours.’
B. ‘There may be a brief sharp pinch as the needle enters the skin.’
C. ‘This catheter will stay in place for several weeks.’
D. ‘The IV fluid will make your arm feel very hot.’
Correct Answer: B
Therapy Q&A with Rationale | Fortis
College
1. A nurse is preparing to administer an isotonic intravenous solution to a patient with fluid
volume deficit. Which of the following solutions should the nurse select?
A. 0.45% Sodium Chloride
B. 10% Dextrose in Water
C. 3% Sodium Chloride
D. 0.9% Sodium Chloride
Correct Answer: D
Expert Explanation: 0.9% Sodium Chloride is considered an isotonic solution because its
osmolarity is similar to that of blood plasma. It expands the extracellular fluid volume
without causing a fluid shift between the intracellular and extracellular compartments.
This makes it the primary choice for initial volume replacement in patients with
dehydration or hypotension.
2. Upon assessment of an IV site, the nurse notes coolness of the skin, edema, and a
significant decrease in the flow rate. Which complication does the nurse suspect?
A. Infiltration
B. Phlebitis
,C. Extravasation
D. Thrombophlebitis
Correct Answer: A
Expert Explanation: Infiltration occurs when a non-vesicant IV solution leaks into the
surrounding subcutaneous tissue. The hallmark signs include local edema, coolness of the
skin near the site, and blanching of the skin. The nurse should immediately stop the
infusion and remove the catheter to prevent further tissue damage.
3. A patient receiving intravenous therapy suddenly develops respiratory distress, chest pain,
and a loud churning sound is heard over the precordium. What is the priority nursing action?
A. Place the patient in the left Trendelenburg position.
B. Place the patient in the high-Fowler’s position.
C. Slow the infusion to a keep-vein-open (KVO) rate.
D. Administer a bolus of 500 mL normal saline.
Correct Answer: A
Expert Explanation: These symptoms are classic indicators of an air embolism, which is a
life-threatening complication of IV therapy. Placing the patient in the left Trendelenburg
position helps trap the air in the apex of the right ventricle, preventing it from entering the
pulmonary artery. The nurse must also notify the healthcare provider immediately and
provide supplemental oxygen.
, 4. The nurse is monitoring a patient receiving a hypertonic IV solution. For which of the
following complications should the nurse be most vigilant?
A. Cerebral edema
B. Fluid volume deficit
C. Hypotension
D. Circulatory overload
Correct Answer: D
Expert Explanation: Hypertonic solutions have a higher osmolarity than plasma, causing
water to be pulled from the intracellular space into the vascular space. This rapid
expansion of blood volume increases the risk of circulatory overload and pulmonary
edema. Nurses must monitor heart sounds, breath sounds, and blood pressure closely
during administration.
5. Which of the following instructions should the nurse provide to a patient who is about to
receive a peripheral IV catheter insertion?
A. ‘You will need to keep your arm perfectly still for the next 24 hours.’
B. ‘There may be a brief sharp pinch as the needle enters the skin.’
C. ‘This catheter will stay in place for several weeks.’
D. ‘The IV fluid will make your arm feel very hot.’
Correct Answer: B
