Nurs saunders medication and therapy exam questions
with answers
1. A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse
making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic,
experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400
mL remaining. The nurse should take which action first?
1. Slow the IV infusion.
2. Sit the client up in bed.
3. Remove the IV catheter.
4. Call the health care provider (HCP).
Answer:
1. Slow the IV infusion.
Rationale:
The client's symptoms are compatible with circulatory overload. This may be verified by noting that 600
mL has infused in the course of 45 minutes. The first action of the nurse is to slow the infusion. Other
actions may follow in rapid sequence. The nurse may elevate the head of the bed to aid the client's
breathing, if necessary. The nurse also notifies the HCP. The IV catheter is not removed; it may be
needed for the administration of medications to resolve the complication.
2. The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with
20 mEq of potassium chloride. The nurse also needs to hang an IV infusion of piperacillin/tazobactam.
The client has one IV site. The nurse should plan to take which action first?
1. Start a second IV site.
2. Check compatibility of the medication and IV fluids.
3. Mix the prepackaged piperacillin/tazobactam per agency policy.
4. Prime the tubing with the IV solution, and back-prime the medication.
Answer:
2. Check compatibility of the medication and IV fluids.
Rationale:
When hanging an IV antibiotic, the nurse should first check compatibility of the medication and the IV
fluids currently prescribed. If the fluids and medication are incompatible, it would then be appropriate
to start a second IV site. If they are compatible, the nurse should hang them together so as to avoid
having to start another IV site. After this, the nurse should prepare the prepackaged
piperacillin/tazobactam per agency policy, then prime the tubing with the IV solution, and then back-
prime the medication. Back- priming prevents any medication from being lost during the priming
process.
3. The nurse is making initial rounds on the nursing unit to assess the condition of assigned
clients. Which assessment findings are consistent with infiltration? Select all that apply.
1. Pain and erythema
2. Pallor and coolness
,Nurs saunders medication and therapy exam questions
with answers
3. Numbness and pain
4. Edema and blanched skin
5. Formation of a red streak and purulent drainage
Answers:
2. Pallor and coolness
3. Numbness and pain
4. Edema and blanched skin
Rationale:
An infiltrated intravenous (IV) line is one that has dislodged from the vein and is lying in subcutaneous
tissue. Pallor, coolness, edema, pain, numbness, and blanched skin are the results of IV fluid being
deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the
tubing, the flow of the IV solution will stop, and if an electronic pump is being used, it will alarm.
Erythema can be associated with infection, phlebitis, or thrombosis. Formation of a red streak and
purulent drainage is associated with phlebitis and infection.
4. The nurse is inserting an intravenous (IV) line into a client's vein. After the initial stick, the nurse would
continue to advance the catheter in which situation?
1. The catheter advances easily.
2. The vein is distended under the needle.
3. The client does not complain of discomfort.
4. Blood return shows in the backflash chamber of the catheter.
Answer:
4. Blood return shows in the backflash chamber of the catheter.
Rationale:
The IV catheter has entered the lumen of the vein successfully when blood backflash shows in the IV
catheter. The vein should have been distended by the tourniquet before the vein was cannulated, and
if further distention occurs after venipuncture, this could mean the needle went through the vein and
into the tissue; therefore, the catheter should not be advanced. Client discomfort varies with the client,
the site, and the nurse's insertion technique and is not a reliable measure of catheter placement. The
nurse should not advance the catheter until placement in the vein is verified by blood return.
5. The nurse is assessing a client's peripheral intravenous (IV) site after completion of a vancomycin
infusion and notes that the area is reddened, warm, painful, and slightly edematous proximal to
the insertion point of the IV catheter. At this time, which action by the nurse is best?
1. Check for the presence of blood return.
2. Remove the IV site and restart at another site.
3. Document the findings and continue to monitor the IV site.
4. Call the health care provider (HCP) and request that the vancomycin be given orally.
Answer:
, Nurs saunders medication and therapy exam questions
with answers
2. Remove the IV site and restart at another site.
Rationale:
Phlebitis at an IV site can be distinguished by client discomfort at the site and by redness, warmth, and
swelling proximal to the catheter. If phlebitis occurs, the nurse should remove the IV line and insert a
new IV line at a different site, in a vein other than the one that has developed phlebitis. Checking for
the presence of blood return should be done before the administration of vancomycin because this
medication is a vesicant. Documenting the findings and continuing to monitor the IV site and calling the
HCP and requesting that the vancomycin be given orally do not address the immediate problem.
Additionally, there could be indications for the prescription of IV as opposed to oral vancomycin for
the client. The HCP should be notified of the complications with the IV site, but not asked for a
prescription for oral vancomycin.
6. The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes
to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of
the medication cart. The nurse should take which action?
1. Obtain a new IV bag.
2. Obtain new IV tubing.
3. Wipe the spike end of the tubing with povidone iodine.
4. Scrub the spike end of the tubing with an alcohol swab.
Answer:
2. Obtain new IV tubing.
Rationale:
The nurse should obtain new IV tubing because contamination has occurred and could cause systemic
infection to the client. There is no need to obtain a new IV bag because the bag was not contaminated.
Wiping with povidone iodine or alcohol is insufficient and is contraindicated because the spike will be
inserted into the IV bag.
7. A health care provider has written a prescription to discontinue an intravenous (IV) line. The nurse
should obtain which item from the unit supply area for applying pressure to the site after removing the
IV catheter?
1. Elastic wrap
2. Povidone iodine swab
3. Adhesive bandage
4. Sterile 2 × 2 gauze
Answer:
4. Sterile 2 × 2 gauze
Rationale:
A dry sterile dressing such as a sterile 2 × 2 gauze is used to apply pressure to the discontinued IV site.
This material is absorbent, sterile, and non-irritating. A povidone iodine swab would irritate the opened
with answers
1. A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse
making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic,
experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400
mL remaining. The nurse should take which action first?
1. Slow the IV infusion.
2. Sit the client up in bed.
3. Remove the IV catheter.
4. Call the health care provider (HCP).
Answer:
1. Slow the IV infusion.
Rationale:
The client's symptoms are compatible with circulatory overload. This may be verified by noting that 600
mL has infused in the course of 45 minutes. The first action of the nurse is to slow the infusion. Other
actions may follow in rapid sequence. The nurse may elevate the head of the bed to aid the client's
breathing, if necessary. The nurse also notifies the HCP. The IV catheter is not removed; it may be
needed for the administration of medications to resolve the complication.
2. The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with
20 mEq of potassium chloride. The nurse also needs to hang an IV infusion of piperacillin/tazobactam.
The client has one IV site. The nurse should plan to take which action first?
1. Start a second IV site.
2. Check compatibility of the medication and IV fluids.
3. Mix the prepackaged piperacillin/tazobactam per agency policy.
4. Prime the tubing with the IV solution, and back-prime the medication.
Answer:
2. Check compatibility of the medication and IV fluids.
Rationale:
When hanging an IV antibiotic, the nurse should first check compatibility of the medication and the IV
fluids currently prescribed. If the fluids and medication are incompatible, it would then be appropriate
to start a second IV site. If they are compatible, the nurse should hang them together so as to avoid
having to start another IV site. After this, the nurse should prepare the prepackaged
piperacillin/tazobactam per agency policy, then prime the tubing with the IV solution, and then back-
prime the medication. Back- priming prevents any medication from being lost during the priming
process.
3. The nurse is making initial rounds on the nursing unit to assess the condition of assigned
clients. Which assessment findings are consistent with infiltration? Select all that apply.
1. Pain and erythema
2. Pallor and coolness
,Nurs saunders medication and therapy exam questions
with answers
3. Numbness and pain
4. Edema and blanched skin
5. Formation of a red streak and purulent drainage
Answers:
2. Pallor and coolness
3. Numbness and pain
4. Edema and blanched skin
Rationale:
An infiltrated intravenous (IV) line is one that has dislodged from the vein and is lying in subcutaneous
tissue. Pallor, coolness, edema, pain, numbness, and blanched skin are the results of IV fluid being
deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the
tubing, the flow of the IV solution will stop, and if an electronic pump is being used, it will alarm.
Erythema can be associated with infection, phlebitis, or thrombosis. Formation of a red streak and
purulent drainage is associated with phlebitis and infection.
4. The nurse is inserting an intravenous (IV) line into a client's vein. After the initial stick, the nurse would
continue to advance the catheter in which situation?
1. The catheter advances easily.
2. The vein is distended under the needle.
3. The client does not complain of discomfort.
4. Blood return shows in the backflash chamber of the catheter.
Answer:
4. Blood return shows in the backflash chamber of the catheter.
Rationale:
The IV catheter has entered the lumen of the vein successfully when blood backflash shows in the IV
catheter. The vein should have been distended by the tourniquet before the vein was cannulated, and
if further distention occurs after venipuncture, this could mean the needle went through the vein and
into the tissue; therefore, the catheter should not be advanced. Client discomfort varies with the client,
the site, and the nurse's insertion technique and is not a reliable measure of catheter placement. The
nurse should not advance the catheter until placement in the vein is verified by blood return.
5. The nurse is assessing a client's peripheral intravenous (IV) site after completion of a vancomycin
infusion and notes that the area is reddened, warm, painful, and slightly edematous proximal to
the insertion point of the IV catheter. At this time, which action by the nurse is best?
1. Check for the presence of blood return.
2. Remove the IV site and restart at another site.
3. Document the findings and continue to monitor the IV site.
4. Call the health care provider (HCP) and request that the vancomycin be given orally.
Answer:
, Nurs saunders medication and therapy exam questions
with answers
2. Remove the IV site and restart at another site.
Rationale:
Phlebitis at an IV site can be distinguished by client discomfort at the site and by redness, warmth, and
swelling proximal to the catheter. If phlebitis occurs, the nurse should remove the IV line and insert a
new IV line at a different site, in a vein other than the one that has developed phlebitis. Checking for
the presence of blood return should be done before the administration of vancomycin because this
medication is a vesicant. Documenting the findings and continuing to monitor the IV site and calling the
HCP and requesting that the vancomycin be given orally do not address the immediate problem.
Additionally, there could be indications for the prescription of IV as opposed to oral vancomycin for
the client. The HCP should be notified of the complications with the IV site, but not asked for a
prescription for oral vancomycin.
6. The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes
to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of
the medication cart. The nurse should take which action?
1. Obtain a new IV bag.
2. Obtain new IV tubing.
3. Wipe the spike end of the tubing with povidone iodine.
4. Scrub the spike end of the tubing with an alcohol swab.
Answer:
2. Obtain new IV tubing.
Rationale:
The nurse should obtain new IV tubing because contamination has occurred and could cause systemic
infection to the client. There is no need to obtain a new IV bag because the bag was not contaminated.
Wiping with povidone iodine or alcohol is insufficient and is contraindicated because the spike will be
inserted into the IV bag.
7. A health care provider has written a prescription to discontinue an intravenous (IV) line. The nurse
should obtain which item from the unit supply area for applying pressure to the site after removing the
IV catheter?
1. Elastic wrap
2. Povidone iodine swab
3. Adhesive bandage
4. Sterile 2 × 2 gauze
Answer:
4. Sterile 2 × 2 gauze
Rationale:
A dry sterile dressing such as a sterile 2 × 2 gauze is used to apply pressure to the discontinued IV site.
This material is absorbent, sterile, and non-irritating. A povidone iodine swab would irritate the opened
