PNR 202/PNR202 Exam 3 V2 | Intravenous
Therapy Q&A with Rationale | Fortis
College
1. A nurse is preparing to administer a 0.9% sodium chloride infusion. How should the nurse
classify this solution?
A. Hypotonic
B. Isotonic
C. Hypertonic
D. Colloid
Correct Answer: B
Expert Explanation: Isotonic solutions such as 0.9% sodium chloride have the same
osmolarity as body fluids. They are primarily used to expand the extracellular fluid volume
without causing a fluid shift between compartments. The nurse must monitor the patient
for signs of fluid volume excess during administration.
2. Upon assessment of a peripheral IV site, the nurse notes coolness, swelling, and the patient
reports tenderness. What is the most likely complication?
A. Phlebitis
B. Infiltration
C. Thrombosis
,D. Infection
Correct Answer: B
Expert Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the
surrounding subcutaneous tissue. Classic signs include skin that is cool to the touch, edema
near the insertion site, and discomfort. The nurse should immediately stop the infusion and
elevate the extremity to promote absorption.
3. When selecting a site for a new peripheral IV in an adult, which action follows best practice
guidelines?
A. Start with the most distal veins of the upper extremities.
B. Always use the dominant hand for comfort.
C. Select the most proximal vein available.
D. Choose a vein in an area of flexion such as the wrist.
Correct Answer: A
Expert Explanation: Best practice for IV site selection dictates starting with distal veins to
preserve more proximal sites for future use. The non-dominant hand is generally preferred
to maintain patient independence and mobility. Avoiding areas of flexion reduces the risk
of mechanical phlebitis and catheter occlusion.
4. A nurse is caring for a patient receiving a rapid IV infusion who suddenly develops dyspnea,
crackles in the lungs, and jugular vein distension. What is the priority nursing action?
A. Speed up the infusion to flush the line.
, B. Administer a bolus of 500 mL Normal Saline.
C. Slow the infusion to a keep-vein-open (KVO) rate and notify the provider.
D. Place the patient in a supine position.
Correct Answer: C
Expert Explanation: The patient is exhibiting classic symptoms of circulatory overload,
which is a common complication of rapid fluid administration. Slowing the rate to KVO
prevents the vein from clotting while stopping the excessive fluid intake. The nurse should
also elevate the head of the bed to facilitate easier breathing.
5. What is the recommended duration for ‘scrubbing the hub’ (the needleless connector) with
an alcohol swab before accessing an IV line?
A. 5 seconds
B. 10 seconds
C. 60 seconds
D. 15 to 30 seconds
Correct Answer: D
Expert Explanation: Evidence-based practice requires scrubbing the needleless connector
for 15 to 30 seconds using friction. This action is critical for preventing catheter-related
bloodstream infections (CRBSI) by removing pathogens. The connector must also be
allowed to air dry completely before being accessed.
Therapy Q&A with Rationale | Fortis
College
1. A nurse is preparing to administer a 0.9% sodium chloride infusion. How should the nurse
classify this solution?
A. Hypotonic
B. Isotonic
C. Hypertonic
D. Colloid
Correct Answer: B
Expert Explanation: Isotonic solutions such as 0.9% sodium chloride have the same
osmolarity as body fluids. They are primarily used to expand the extracellular fluid volume
without causing a fluid shift between compartments. The nurse must monitor the patient
for signs of fluid volume excess during administration.
2. Upon assessment of a peripheral IV site, the nurse notes coolness, swelling, and the patient
reports tenderness. What is the most likely complication?
A. Phlebitis
B. Infiltration
C. Thrombosis
,D. Infection
Correct Answer: B
Expert Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the
surrounding subcutaneous tissue. Classic signs include skin that is cool to the touch, edema
near the insertion site, and discomfort. The nurse should immediately stop the infusion and
elevate the extremity to promote absorption.
3. When selecting a site for a new peripheral IV in an adult, which action follows best practice
guidelines?
A. Start with the most distal veins of the upper extremities.
B. Always use the dominant hand for comfort.
C. Select the most proximal vein available.
D. Choose a vein in an area of flexion such as the wrist.
Correct Answer: A
Expert Explanation: Best practice for IV site selection dictates starting with distal veins to
preserve more proximal sites for future use. The non-dominant hand is generally preferred
to maintain patient independence and mobility. Avoiding areas of flexion reduces the risk
of mechanical phlebitis and catheter occlusion.
4. A nurse is caring for a patient receiving a rapid IV infusion who suddenly develops dyspnea,
crackles in the lungs, and jugular vein distension. What is the priority nursing action?
A. Speed up the infusion to flush the line.
, B. Administer a bolus of 500 mL Normal Saline.
C. Slow the infusion to a keep-vein-open (KVO) rate and notify the provider.
D. Place the patient in a supine position.
Correct Answer: C
Expert Explanation: The patient is exhibiting classic symptoms of circulatory overload,
which is a common complication of rapid fluid administration. Slowing the rate to KVO
prevents the vein from clotting while stopping the excessive fluid intake. The nurse should
also elevate the head of the bed to facilitate easier breathing.
5. What is the recommended duration for ‘scrubbing the hub’ (the needleless connector) with
an alcohol swab before accessing an IV line?
A. 5 seconds
B. 10 seconds
C. 60 seconds
D. 15 to 30 seconds
Correct Answer: D
Expert Explanation: Evidence-based practice requires scrubbing the needleless connector
for 15 to 30 seconds using friction. This action is critical for preventing catheter-related
bloodstream infections (CRBSI) by removing pathogens. The connector must also be
allowed to air dry completely before being accessed.
