PNR 202/PNR202 Final Exam V3 |
Intravenous Therapy Q&A with Rationale |
Fortis College
1. A nurse is assessing a patient’s IV site and notes coolness of the skin, edema, and a slowed
infusion rate. Which complication does the nurse suspect?
A. Phlebitis
B. Septicemia
C. Infiltration
D. Extravasation
Correct Answer: C
Expert Explanation: Infiltration occurs when IV fluid leaks into the surrounding
subcutaneous tissue rather than the vein. Key signs include coolness, swelling, and
discomfort at the site, along with a decreased flow rate. The nurse must stop the infusion
and remove the catheter immediately to prevent further tissue damage.
2. When administering a hypertonic solution such as 5% Dextrose in 0.9% Sodium Chloride
(D5NS), what is the primary physiological effect on the cells?
A. Cells swell as fluid moves from the intravascular space into the intracellular space.
B. There is no net movement of water between the compartments.
C. Cells shrink as fluid is pulled from the intracellular space into the intravascular space.
,D. Fluid moves into the interstitial space causing generalized edema.
Correct Answer: C
Expert Explanation: Hypertonic solutions have a higher osmolarity than serum, which
creates an osmotic pressure gradient. This gradient pulls water out of the cells and into the
bloodstream, causing the cells to shrink. Nurses must monitor patients closely for signs of
fluid volume overload when using these solutions.
3. The nurse is preparing to hang a secondary IV piggyback (IVPB) medication. Where should
the secondary bag be placed in relation to the primary IV bag for gravity infusion?
A. Higher than the primary bag
B. At the same level as the primary bag
C. Lower than the primary bag
D. Taped to the primary bag
Correct Answer: A
Expert Explanation: For gravity-driven infusions, the secondary bag must be hung higher
than the primary bag. This creates higher hydrostatic pressure in the secondary line, which
allows it to flow first. Once the secondary bag is empty, the primary infusion will
automatically resume due to the pressure change.
4. A patient receiving IV therapy reports sudden chest pain, cough, and dyspnea. The nurse
notes cyanosis and a rapid, weak pulse. What is the priority nursing action?
A. Slow the IV rate to keep vein open (KVO).
, B. Apply a warm compress to the IV site.
C. Administer a bolus of Normal Saline.
D. Place the patient on their left side in Trendelenburg position.
Correct Answer: D
Expert Explanation: These symptoms are classic signs of an air embolism, which is a life-
threatening emergency. Placing the patient on the left side in Trendelenburg position helps
trap the air in the apex of the right ventricle, preventing it from entering the pulmonary
artery. The nurse should then notify the rapid response team and provide oxygen.
5. Which of the following is a key symptom that distinguishes phlebitis from infiltration?
A. Coolness of the skin
B. Edema at the site
C. Warmth and redness along the vein path
D. Dampness of the dressing
Correct Answer: C
Expert Explanation: Phlebitis is characterized by inflammation of the vein, which presents
as warmth, redness, and sometimes a palpable cord. In contrast, infiltration causes the skin
to feel cool and appear pale. Proper assessment is critical to determine the appropriate
intervention for each complication.
Intravenous Therapy Q&A with Rationale |
Fortis College
1. A nurse is assessing a patient’s IV site and notes coolness of the skin, edema, and a slowed
infusion rate. Which complication does the nurse suspect?
A. Phlebitis
B. Septicemia
C. Infiltration
D. Extravasation
Correct Answer: C
Expert Explanation: Infiltration occurs when IV fluid leaks into the surrounding
subcutaneous tissue rather than the vein. Key signs include coolness, swelling, and
discomfort at the site, along with a decreased flow rate. The nurse must stop the infusion
and remove the catheter immediately to prevent further tissue damage.
2. When administering a hypertonic solution such as 5% Dextrose in 0.9% Sodium Chloride
(D5NS), what is the primary physiological effect on the cells?
A. Cells swell as fluid moves from the intravascular space into the intracellular space.
B. There is no net movement of water between the compartments.
C. Cells shrink as fluid is pulled from the intracellular space into the intravascular space.
,D. Fluid moves into the interstitial space causing generalized edema.
Correct Answer: C
Expert Explanation: Hypertonic solutions have a higher osmolarity than serum, which
creates an osmotic pressure gradient. This gradient pulls water out of the cells and into the
bloodstream, causing the cells to shrink. Nurses must monitor patients closely for signs of
fluid volume overload when using these solutions.
3. The nurse is preparing to hang a secondary IV piggyback (IVPB) medication. Where should
the secondary bag be placed in relation to the primary IV bag for gravity infusion?
A. Higher than the primary bag
B. At the same level as the primary bag
C. Lower than the primary bag
D. Taped to the primary bag
Correct Answer: A
Expert Explanation: For gravity-driven infusions, the secondary bag must be hung higher
than the primary bag. This creates higher hydrostatic pressure in the secondary line, which
allows it to flow first. Once the secondary bag is empty, the primary infusion will
automatically resume due to the pressure change.
4. A patient receiving IV therapy reports sudden chest pain, cough, and dyspnea. The nurse
notes cyanosis and a rapid, weak pulse. What is the priority nursing action?
A. Slow the IV rate to keep vein open (KVO).
, B. Apply a warm compress to the IV site.
C. Administer a bolus of Normal Saline.
D. Place the patient on their left side in Trendelenburg position.
Correct Answer: D
Expert Explanation: These symptoms are classic signs of an air embolism, which is a life-
threatening emergency. Placing the patient on the left side in Trendelenburg position helps
trap the air in the apex of the right ventricle, preventing it from entering the pulmonary
artery. The nurse should then notify the rapid response team and provide oxygen.
5. Which of the following is a key symptom that distinguishes phlebitis from infiltration?
A. Coolness of the skin
B. Edema at the site
C. Warmth and redness along the vein path
D. Dampness of the dressing
Correct Answer: C
Expert Explanation: Phlebitis is characterized by inflammation of the vein, which presents
as warmth, redness, and sometimes a palpable cord. In contrast, infiltration causes the skin
to feel cool and appear pale. Proper assessment is critical to determine the appropriate
intervention for each complication.
