PNR 202/PNR202 Exam 2 V1 | Intravenous
Therapy Q&A with Rationale | Fortis
College
1. A nurse assesses an IV site and notes coolness, swelling, and pallor. The patient complains
of tightness at the site. Which complication should the nurse suspect?
A. Phlebitis
B. Extravasation
C. Infiltration
D. Septicemia
Correct Answer: C
Expert Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the
surrounding tissue rather than staying in the vein. The primary clinical signs include local
edema, skin that is cool to the touch, and blanching or pallor. The nurse must immediately
stop the infusion and remove the catheter as per standard nursing protocols.
2. When preparing to administer 1,000 mL of 0.9% Normal Saline over 8 hours using a gravity
drip set with a drop factor of 15 gtt/mL, what is the correct flow rate?
A. 21 gtt/min
B. 42 gtt/min
C. 31 gtt/min
,D. 125 gtt/min
Correct Answer: C
Expert Explanation: To calculate the drip rate, first determine the total minutes (8 hours x
60 minutes = 480 minutes). Then, use the formula (Volume in mL x Drop Factor) / Time in
Minutes: (1,000 x 15) / 480 = 31.25. Rounding to the nearest whole number yields 31
drops per minute.
3. Which clinical manifestation specifically differentiates phlebitis from infiltration?
A. Swelling around the insertion site
B. Sluggish flow of the IV fluid
C. Dampness of the dressing
D. Erythema and warmth along the vein path
Correct Answer: D
Expert Explanation: Phlebitis is the inflammation of the inner lining of the vein, which
results in redness, heat, and a palpable cord-like feeling. In contrast, infiltration typically
involves cool skin and pallor rather than warmth and erythema. Monitoring for these
specific inflammatory markers is a critical component of IV site assessment.
4. A patient receiving IV therapy reports sudden shortness of breath, cough, and a ‘doom-like’
feeling. The nurse notes distended neck veins and crackles in the lungs. What is the priority
action?
A. Speed up the IV to increase blood pressure
, B. Place the patient in Trendelenburg position
C. Slow the IV to a ‘keep-open’ rate and elevate the head of the bed
D. Stop the IV and notify the provider
Correct Answer: C
Expert Explanation: These symptoms indicate circulatory overload, where the fluid
volume is too high for the heart to manage. Elevating the head of the bed helps ease
respiratory distress by reducing the work of breathing. Slowing the rate to KVO (Keep Vein
Open) prevents further overload while maintaining access for emergency medications.
5. A nurse is preparing to hang a bag of Total Parenteral Nutrition (TPN). Which lab value is
most important to monitor regularly for this patient?
A. Blood Glucose
B. Prothrombin Time (PT)
C. Serum Creatinine
D. Hemoglobin
Correct Answer: A
Expert Explanation: TPN contains a high concentration of dextrose, which places the
patient at a significant risk for hyperglycemia. Standard protocol requires checking blood
glucose levels every 6 hours or as ordered by the physician. If TPN is stopped abruptly, the
patient may also experience rebound hypoglycemia, requiring further monitoring.
Therapy Q&A with Rationale | Fortis
College
1. A nurse assesses an IV site and notes coolness, swelling, and pallor. The patient complains
of tightness at the site. Which complication should the nurse suspect?
A. Phlebitis
B. Extravasation
C. Infiltration
D. Septicemia
Correct Answer: C
Expert Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the
surrounding tissue rather than staying in the vein. The primary clinical signs include local
edema, skin that is cool to the touch, and blanching or pallor. The nurse must immediately
stop the infusion and remove the catheter as per standard nursing protocols.
2. When preparing to administer 1,000 mL of 0.9% Normal Saline over 8 hours using a gravity
drip set with a drop factor of 15 gtt/mL, what is the correct flow rate?
A. 21 gtt/min
B. 42 gtt/min
C. 31 gtt/min
,D. 125 gtt/min
Correct Answer: C
Expert Explanation: To calculate the drip rate, first determine the total minutes (8 hours x
60 minutes = 480 minutes). Then, use the formula (Volume in mL x Drop Factor) / Time in
Minutes: (1,000 x 15) / 480 = 31.25. Rounding to the nearest whole number yields 31
drops per minute.
3. Which clinical manifestation specifically differentiates phlebitis from infiltration?
A. Swelling around the insertion site
B. Sluggish flow of the IV fluid
C. Dampness of the dressing
D. Erythema and warmth along the vein path
Correct Answer: D
Expert Explanation: Phlebitis is the inflammation of the inner lining of the vein, which
results in redness, heat, and a palpable cord-like feeling. In contrast, infiltration typically
involves cool skin and pallor rather than warmth and erythema. Monitoring for these
specific inflammatory markers is a critical component of IV site assessment.
4. A patient receiving IV therapy reports sudden shortness of breath, cough, and a ‘doom-like’
feeling. The nurse notes distended neck veins and crackles in the lungs. What is the priority
action?
A. Speed up the IV to increase blood pressure
, B. Place the patient in Trendelenburg position
C. Slow the IV to a ‘keep-open’ rate and elevate the head of the bed
D. Stop the IV and notify the provider
Correct Answer: C
Expert Explanation: These symptoms indicate circulatory overload, where the fluid
volume is too high for the heart to manage. Elevating the head of the bed helps ease
respiratory distress by reducing the work of breathing. Slowing the rate to KVO (Keep Vein
Open) prevents further overload while maintaining access for emergency medications.
5. A nurse is preparing to hang a bag of Total Parenteral Nutrition (TPN). Which lab value is
most important to monitor regularly for this patient?
A. Blood Glucose
B. Prothrombin Time (PT)
C. Serum Creatinine
D. Hemoglobin
Correct Answer: A
Expert Explanation: TPN contains a high concentration of dextrose, which places the
patient at a significant risk for hyperglycemia. Standard protocol requires checking blood
glucose levels every 6 hours or as ordered by the physician. If TPN is stopped abruptly, the
patient may also experience rebound hypoglycemia, requiring further monitoring.
