PNR 202/PNR202 Final Exam V1 |
Intravenous Therapy Q&A with Rationale |
Fortis College
1. A nurse is assessing a patient’s peripheral IV site and notes coolness, swelling, and a
slowed infusion rate. Which complication should the nurse suspect?
A. Phlebitis
B. Infiltration
C. Extravasation
D. Septicemia
Correct Answer: B
Expert Explanation: Infiltration is characterized by the leakage of non-vesicant IV fluid
into the subcutaneous tissue, resulting in coolness and edema. The nurse must stop the
infusion and remove the catheter immediately to prevent further tissue damage. Elevating
the affected extremity is also a standard intervention to facilitate fluid reabsorption.
2. When administering a hypertonic solution such as 3% Sodium Chloride, how does the fluid
shift within the body?
A. Fluid moves from the intracellular space to the extracellular space.
B. Fluid moves from the extracellular space to the intracellular space.
C. There is no net movement of fluid between compartments.
,D. Fluid moves into the interstitial space only.
Correct Answer: A
Expert Explanation: Hypertonic solutions have a higher osmolarity than the serum, which
creates an osmotic pull. This causes water to leave the cells and enter the vascular space to
balance the concentration. Nurses must monitor for signs of fluid volume excess when
administering these types of fluids.
3. A patient suddenly develops dyspnea, cyanosis, and a loud churning sound is heard over
the precordium during auscultation. What is the priority nursing action?
A. Place the patient in High-Fowler’s position.
B. Administer a bolus of Normal Saline.
C. Apply a warm compress to the IV site.
D. Place the patient on the left side in Trendelenburg position.
Correct Answer: D
Expert Explanation: These symptoms are classic indicators of an air embolism, which is a
life-threatening emergency. Placing the patient on the left side in Trendelenburg traps the
air in the right atrium and prevents it from entering the pulmonary artery. The nurse must
also notify the physician immediately and provide oxygen support.
4. Which gauge size is most appropriate for a patient who requires a rapid blood transfusion
in an emergency setting?
A. 24-gauge
, B. 22-gauge
C. 18-gauge
D. 26-gauge
Correct Answer: C
Expert Explanation: An 18-gauge needle is preferred for blood transfusions because the
larger lumen prevents hemolysis of red blood cells. Using a smaller gauge like 22 or 24 can
cause damage to the cells and slow down the administration rate significantly. In
emergency situations, large-bore access is critical for rapid fluid resuscitation.
5. The nurse observes a red streak following the vein path and the patient reports pain at the
IV site. Using the phlebitis scale, how would this be graded?
A. Grade 1
B. Grade 3
C. Grade 2
D. Grade 4
Correct Answer: B
Expert Explanation: Grade 3 phlebitis is defined by pain at the access site with erythema
and streak formation. A palpable venous cord would indicate Grade 4, while Grade 2 only
involves pain and erythema without streak formation. This condition requires immediate
removal of the IV catheter and application of a warm compress.
Intravenous Therapy Q&A with Rationale |
Fortis College
1. A nurse is assessing a patient’s peripheral IV site and notes coolness, swelling, and a
slowed infusion rate. Which complication should the nurse suspect?
A. Phlebitis
B. Infiltration
C. Extravasation
D. Septicemia
Correct Answer: B
Expert Explanation: Infiltration is characterized by the leakage of non-vesicant IV fluid
into the subcutaneous tissue, resulting in coolness and edema. The nurse must stop the
infusion and remove the catheter immediately to prevent further tissue damage. Elevating
the affected extremity is also a standard intervention to facilitate fluid reabsorption.
2. When administering a hypertonic solution such as 3% Sodium Chloride, how does the fluid
shift within the body?
A. Fluid moves from the intracellular space to the extracellular space.
B. Fluid moves from the extracellular space to the intracellular space.
C. There is no net movement of fluid between compartments.
,D. Fluid moves into the interstitial space only.
Correct Answer: A
Expert Explanation: Hypertonic solutions have a higher osmolarity than the serum, which
creates an osmotic pull. This causes water to leave the cells and enter the vascular space to
balance the concentration. Nurses must monitor for signs of fluid volume excess when
administering these types of fluids.
3. A patient suddenly develops dyspnea, cyanosis, and a loud churning sound is heard over
the precordium during auscultation. What is the priority nursing action?
A. Place the patient in High-Fowler’s position.
B. Administer a bolus of Normal Saline.
C. Apply a warm compress to the IV site.
D. Place the patient on the left side in Trendelenburg position.
Correct Answer: D
Expert Explanation: These symptoms are classic indicators of an air embolism, which is a
life-threatening emergency. Placing the patient on the left side in Trendelenburg traps the
air in the right atrium and prevents it from entering the pulmonary artery. The nurse must
also notify the physician immediately and provide oxygen support.
4. Which gauge size is most appropriate for a patient who requires a rapid blood transfusion
in an emergency setting?
A. 24-gauge
, B. 22-gauge
C. 18-gauge
D. 26-gauge
Correct Answer: C
Expert Explanation: An 18-gauge needle is preferred for blood transfusions because the
larger lumen prevents hemolysis of red blood cells. Using a smaller gauge like 22 or 24 can
cause damage to the cells and slow down the administration rate significantly. In
emergency situations, large-bore access is critical for rapid fluid resuscitation.
5. The nurse observes a red streak following the vein path and the patient reports pain at the
IV site. Using the phlebitis scale, how would this be graded?
A. Grade 1
B. Grade 3
C. Grade 2
D. Grade 4
Correct Answer: B
Expert Explanation: Grade 3 phlebitis is defined by pain at the access site with erythema
and streak formation. A palpable venous cord would indicate Grade 4, while Grade 2 only
involves pain and erythema without streak formation. This condition requires immediate
removal of the IV catheter and application of a warm compress.
