PNR 202/PNR202 Exam 3 V1 | Intravenous
Therapy Q&A with Rationale | Fortis
College
1. A nurse is assessing a patient’s peripheral IV site and notes that the area is cool to the
touch, swollen, and the infusion rate has slowed. Which complication is the patient most
likely experiencing?
A. Phlebitis
B. Extravasation
C. Infiltration
D. Air Embolism
Correct Answer: C
Expert Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the
surrounding subcutaneous tissue, causing coolness and edema. The nurse should
immediately stop the infusion and remove the catheter. Proper assessment involves
comparing the site to the opposite extremity to confirm swelling.
2. Which of the following IV solutions is classified as hypotonic?
A. 0.9% Normal Saline
B. Lactated Ringer’s
C. 0.45% Sodium Chloride
,D. 5% Dextrose in 0.9% Normal Saline
Correct Answer: C
Expert Explanation: 0.45% Sodium Chloride, also known as half-normal saline, is a
hypotonic solution because it has a lower osmolarity than plasma. Hypotonic solutions
cause fluid to shift from the intravascular space into the intracellular space. This is often
used to treat cellular dehydration but must be monitored to prevent cerebral edema.
3. The nurse is preparing to administer a blood transfusion. Which size gauge catheter is the
minimum recommended for a standard adult transfusion to prevent hemolysis?
A. 24-gauge
B. 22-gauge
C. 20-gauge
D. 18-gauge
Correct Answer: C
Expert Explanation: While an 18-gauge is preferred for rapid infusions, a 20-gauge is
generally considered the minimum size for routine blood transfusions in adults to prevent
damage to red blood cells. Using a smaller gauge like 22 or 24 increases the risk of
hemolysis during the procedure. The nurse must ensure patency and blood return before
starting the transfusion.
, 4. A patient receiving IV therapy suddenly develops respiratory distress, chest pain, and
hypotension. The nurse suspects an air embolism. What is the priority nursing action?
A. Place the patient in Trendelenburg on the left side.
B. Elevate the head of the bed to High-Fowler’s.
C. Slow the IV rate to keep the vein open.
D. Administer a bolus of Normal Saline.
Correct Answer: A
Expert Explanation: Placing the patient in the left lateral Trendelenburg position helps
trap the air bubble in the apex of the right ventricle, preventing it from entering the
pulmonary artery. The nurse should also notify the healthcare provider and administer
oxygen immediately. This is a medical emergency that requires rapid intervention to
prevent cardiac arrest.
5. A nurse notes a red, warm streak following the vein path above an IV insertion site. The
patient reports pain at the site. How should the nurse document this finding?
A. Infiltration Grade 2
B. Infection at the site
C. Phlebitis Grade 3
D. Hematoma formation
Correct Answer: C
Therapy Q&A with Rationale | Fortis
College
1. A nurse is assessing a patient’s peripheral IV site and notes that the area is cool to the
touch, swollen, and the infusion rate has slowed. Which complication is the patient most
likely experiencing?
A. Phlebitis
B. Extravasation
C. Infiltration
D. Air Embolism
Correct Answer: C
Expert Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the
surrounding subcutaneous tissue, causing coolness and edema. The nurse should
immediately stop the infusion and remove the catheter. Proper assessment involves
comparing the site to the opposite extremity to confirm swelling.
2. Which of the following IV solutions is classified as hypotonic?
A. 0.9% Normal Saline
B. Lactated Ringer’s
C. 0.45% Sodium Chloride
,D. 5% Dextrose in 0.9% Normal Saline
Correct Answer: C
Expert Explanation: 0.45% Sodium Chloride, also known as half-normal saline, is a
hypotonic solution because it has a lower osmolarity than plasma. Hypotonic solutions
cause fluid to shift from the intravascular space into the intracellular space. This is often
used to treat cellular dehydration but must be monitored to prevent cerebral edema.
3. The nurse is preparing to administer a blood transfusion. Which size gauge catheter is the
minimum recommended for a standard adult transfusion to prevent hemolysis?
A. 24-gauge
B. 22-gauge
C. 20-gauge
D. 18-gauge
Correct Answer: C
Expert Explanation: While an 18-gauge is preferred for rapid infusions, a 20-gauge is
generally considered the minimum size for routine blood transfusions in adults to prevent
damage to red blood cells. Using a smaller gauge like 22 or 24 increases the risk of
hemolysis during the procedure. The nurse must ensure patency and blood return before
starting the transfusion.
, 4. A patient receiving IV therapy suddenly develops respiratory distress, chest pain, and
hypotension. The nurse suspects an air embolism. What is the priority nursing action?
A. Place the patient in Trendelenburg on the left side.
B. Elevate the head of the bed to High-Fowler’s.
C. Slow the IV rate to keep the vein open.
D. Administer a bolus of Normal Saline.
Correct Answer: A
Expert Explanation: Placing the patient in the left lateral Trendelenburg position helps
trap the air bubble in the apex of the right ventricle, preventing it from entering the
pulmonary artery. The nurse should also notify the healthcare provider and administer
oxygen immediately. This is a medical emergency that requires rapid intervention to
prevent cardiac arrest.
5. A nurse notes a red, warm streak following the vein path above an IV insertion site. The
patient reports pain at the site. How should the nurse document this finding?
A. Infiltration Grade 2
B. Infection at the site
C. Phlebitis Grade 3
D. Hematoma formation
Correct Answer: C
