PNR 202/PNR202 Exam 1 V2 | Intravenous
Therapy Q&A with Rationale | Fortis
College
1. A nurse is assessing a patient’s peripheral IV site and notes that the skin is cool to the
touch, blanched, and has moderate edema. Which complication of IV therapy does this
indicate?
A. Infiltration
B. Phlebitis
C. Air Embolism
D. Septicemia
Correct Answer: A
Expert Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the
surrounding subcutaneous tissue, causing localized coolness and blanching. Phlebitis
would present with warmth and redness rather than coolness. The nurse should
immediately stop the infusion and remove the catheter to prevent further tissue damage.
2. When selecting a vein for a peripheral IV insertion in an adult patient, which of the
following veins should the nurse attempt to use first?
A. The cephalic vein in the antecubital fossa
B. The most proximal vein near the axilla
,C. The most distal vein on the non-dominant arm
D. The great saphenous vein in the leg
Correct Answer: C
Expert Explanation: Starting at the most distal point allows for subsequent attempts to be
made moving proximally up the arm if the first attempt fails. Using the non-dominant arm
helps maintain the patient’s independence and comfort during therapy. Antecubital sites
are generally avoided for routine access because they limit joint mobility and are prone to
occlusion.
3. Which of the following intravenous solutions is classified as hypotonic?
A. 0.9% Sodium Chloride (Normal Saline)
B. 0.45% Sodium Chloride (Half Normal Saline)
C. Lactated Ringer’s
D. 5% Dextrose in 0.9% Sodium Chloride
Correct Answer: B
Expert Explanation: Hypotonic solutions have a lower osmolality than human blood,
causing water to move from the extracellular space into the cells. 0.45% Sodium Chloride is
a common hypotonic fluid used to treat cellular dehydration. In contrast, 0.9% NaCl and
Lactated Ringer’s are isotonic, while D5NS is hypertonic.
, 4. A nurse notes a red streak following the path of the vein and warmth at the IV site. What is
the priority nursing intervention?
A. Slow the infusion rate to keep the vein open
B. Apply a cold compress to the site
C. Discontinue the IV and restart it at a different site
D. Flush the line with heparinized saline
Correct Answer: C
Expert Explanation: These signs are classic indicators of phlebitis, which is an
inflammation of the inner lining of the vein. Continuing the infusion will worsen the
inflammation and potentially lead to thrombus formation. The nurse must remove the
catheter and apply a warm compress to improve circulation and reduce discomfort.
5. Which gauge size is most appropriate for a patient who is scheduled to receive a blood
transfusion?
A. 18 gauge
B. 24 gauge
C. 26 gauge
D. 22 gauge
Correct Answer: A
Therapy Q&A with Rationale | Fortis
College
1. A nurse is assessing a patient’s peripheral IV site and notes that the skin is cool to the
touch, blanched, and has moderate edema. Which complication of IV therapy does this
indicate?
A. Infiltration
B. Phlebitis
C. Air Embolism
D. Septicemia
Correct Answer: A
Expert Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the
surrounding subcutaneous tissue, causing localized coolness and blanching. Phlebitis
would present with warmth and redness rather than coolness. The nurse should
immediately stop the infusion and remove the catheter to prevent further tissue damage.
2. When selecting a vein for a peripheral IV insertion in an adult patient, which of the
following veins should the nurse attempt to use first?
A. The cephalic vein in the antecubital fossa
B. The most proximal vein near the axilla
,C. The most distal vein on the non-dominant arm
D. The great saphenous vein in the leg
Correct Answer: C
Expert Explanation: Starting at the most distal point allows for subsequent attempts to be
made moving proximally up the arm if the first attempt fails. Using the non-dominant arm
helps maintain the patient’s independence and comfort during therapy. Antecubital sites
are generally avoided for routine access because they limit joint mobility and are prone to
occlusion.
3. Which of the following intravenous solutions is classified as hypotonic?
A. 0.9% Sodium Chloride (Normal Saline)
B. 0.45% Sodium Chloride (Half Normal Saline)
C. Lactated Ringer’s
D. 5% Dextrose in 0.9% Sodium Chloride
Correct Answer: B
Expert Explanation: Hypotonic solutions have a lower osmolality than human blood,
causing water to move from the extracellular space into the cells. 0.45% Sodium Chloride is
a common hypotonic fluid used to treat cellular dehydration. In contrast, 0.9% NaCl and
Lactated Ringer’s are isotonic, while D5NS is hypertonic.
, 4. A nurse notes a red streak following the path of the vein and warmth at the IV site. What is
the priority nursing intervention?
A. Slow the infusion rate to keep the vein open
B. Apply a cold compress to the site
C. Discontinue the IV and restart it at a different site
D. Flush the line with heparinized saline
Correct Answer: C
Expert Explanation: These signs are classic indicators of phlebitis, which is an
inflammation of the inner lining of the vein. Continuing the infusion will worsen the
inflammation and potentially lead to thrombus formation. The nurse must remove the
catheter and apply a warm compress to improve circulation and reduce discomfort.
5. Which gauge size is most appropriate for a patient who is scheduled to receive a blood
transfusion?
A. 18 gauge
B. 24 gauge
C. 26 gauge
D. 22 gauge
Correct Answer: A
