PNR 202/PNR202 Exam 4 V2 | Intravenous
Therapy Q&A with Rationale | Fortis
College
1. A nurse is assessing an intravenous (IV) site and finds the area is cool to the touch, swollen,
and the infusion has slowed. Which complication is the nurse likely observing?
A. Phlebitis
B. Thrombophlebitis
C. Extravasation
D. Infiltration
Correct Answer: D
Expert Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the
surrounding subcutaneous tissue. Common signs include coolness, edema around the site,
and a dampened flow rate. The nurse must stop the infusion and elevate the extremity to
promote fluid reabsorption.
2. Which of the following IV solutions is classified as hypotonic?
A. 0.45% Sodium Chloride (1/2 NS)
B. Lactated Ringer’s (LR)
C. 0.9% Sodium Chloride (NS)
D. 5% Dextrose in 0.9% Sodium Chloride (D5NS)
,Correct Answer: A
Expert Explanation: Hypotonic solutions have a lower osmolarity than plasma, causing
fluid to move from the vascular space into the cells. 0.45% Sodium Chloride is a common
hypotonic solution used to treat cellular dehydration. This type of solution must be used
cautiously to avoid causing cerebral edema in susceptible patients.
3. A patient receiving a blood transfusion begins to experience chills, fever, and low back
pain. What is the priority nursing action?
A. Slow the infusion and notify the provider
B. Stop the transfusion immediately
C. Administer acetaminophen as ordered
D. Check the patient’s temperature every 15 minutes
Correct Answer: B
Expert Explanation: Low back pain, chills, and fever during a blood transfusion are classic
signs of a hemolytic reaction. The priority intervention is to stop the transfusion
immediately to prevent further damage. The nurse should then maintain the line with
normal saline and notify the provider and blood bank.
4. When initiating a peripheral IV, which site should the nurse select first to preserve future
access?
A. Antecubital fossa
B. Dorsum of the hand
, C. Distal veins of the arm
D. Veins in the foot
Correct Answer: C
Expert Explanation: Best practice for IV initiation is to start with the most distal veins of
the upper extremities. This approach allows for subsequent proximal attempts if the initial
site fails or is discontinued. Avoiding the antecubital fossa for routine access is preferred to
prevent movement-related complications.
5. The nurse is monitoring a patient receiving a hypertonic IV solution. Which clinical finding
should the nurse be most concerned about?
A. Crackles upon lung auscultation
B. Dry mucous membranes
C. Decreased urine output
D. Flat neck veins
Correct Answer: A
Expert Explanation: Hypertonic solutions draw fluid from the intracellular space into the
vascular space, increasing the risk of fluid volume overload. Crackles in the lungs are an
early sign of pulmonary edema associated with fluid overload. The nurse must monitor
cardiovascular and respiratory status closely during administration.
Therapy Q&A with Rationale | Fortis
College
1. A nurse is assessing an intravenous (IV) site and finds the area is cool to the touch, swollen,
and the infusion has slowed. Which complication is the nurse likely observing?
A. Phlebitis
B. Thrombophlebitis
C. Extravasation
D. Infiltration
Correct Answer: D
Expert Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the
surrounding subcutaneous tissue. Common signs include coolness, edema around the site,
and a dampened flow rate. The nurse must stop the infusion and elevate the extremity to
promote fluid reabsorption.
2. Which of the following IV solutions is classified as hypotonic?
A. 0.45% Sodium Chloride (1/2 NS)
B. Lactated Ringer’s (LR)
C. 0.9% Sodium Chloride (NS)
D. 5% Dextrose in 0.9% Sodium Chloride (D5NS)
,Correct Answer: A
Expert Explanation: Hypotonic solutions have a lower osmolarity than plasma, causing
fluid to move from the vascular space into the cells. 0.45% Sodium Chloride is a common
hypotonic solution used to treat cellular dehydration. This type of solution must be used
cautiously to avoid causing cerebral edema in susceptible patients.
3. A patient receiving a blood transfusion begins to experience chills, fever, and low back
pain. What is the priority nursing action?
A. Slow the infusion and notify the provider
B. Stop the transfusion immediately
C. Administer acetaminophen as ordered
D. Check the patient’s temperature every 15 minutes
Correct Answer: B
Expert Explanation: Low back pain, chills, and fever during a blood transfusion are classic
signs of a hemolytic reaction. The priority intervention is to stop the transfusion
immediately to prevent further damage. The nurse should then maintain the line with
normal saline and notify the provider and blood bank.
4. When initiating a peripheral IV, which site should the nurse select first to preserve future
access?
A. Antecubital fossa
B. Dorsum of the hand
, C. Distal veins of the arm
D. Veins in the foot
Correct Answer: C
Expert Explanation: Best practice for IV initiation is to start with the most distal veins of
the upper extremities. This approach allows for subsequent proximal attempts if the initial
site fails or is discontinued. Avoiding the antecubital fossa for routine access is preferred to
prevent movement-related complications.
5. The nurse is monitoring a patient receiving a hypertonic IV solution. Which clinical finding
should the nurse be most concerned about?
A. Crackles upon lung auscultation
B. Dry mucous membranes
C. Decreased urine output
D. Flat neck veins
Correct Answer: A
Expert Explanation: Hypertonic solutions draw fluid from the intracellular space into the
vascular space, increasing the risk of fluid volume overload. Crackles in the lungs are an
early sign of pulmonary edema associated with fluid overload. The nurse must monitor
cardiovascular and respiratory status closely during administration.
