Chapter 35: Intravenous Medications
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. A patient is to have an IV insertion site changed. The current line is in the lower right
forearm. Which location is contraindicated for the new site?
a. Right upper forearm
b. Right hand
c. Left upper forearm
d. Left hand
ANS: B
A new IV site should not be placed distal to an old site; the right hand is distal to the
right forearm, so it should not be used.
DIF: Cognitive Level: Analysis REF: m 710 OBJ: Clinical Practice #4
TOP: Changing IV Site KEY: Nursing Process Step:
Planning MSC: NCLEX: Physiological Integrity: reduction of risk
potential
2. The nurse would plan to get another nurse to try to obtain a successful venipuncture if the
first nurse was not successful in _____ attempt(s).
a. five
b. three
c. two
d. one
ANS: C
If the nurse cannot initiate a patent IV in two attempts, it is good judgment to ask
another nurse to perform the task.
DIF: Cognitive Level: Application REF: m 715, Skill 36-1 OBJ:
Clinical Practice #4 TOP: Starting an IV KEY: Nursing Process
Step: Planning MSC: NCLEX: Physiological Integrity: basic
care and comfort
3. A nurse is aware that for a patient with a continuous IV infusion running, the IV bag
should be changed when only ______ mL of solution remains in the bag.
a. 10
b. 25
c. 50
d. 100
ANS: C
When the container has only 50 mL of solution left, the next ordered solution is added
to the setup and the flow begun to prevent air from entering the line.
DIF: Cognitive Level: Comprehension REF: m 716 OBJ: Clinical
Practice #5 TOP: Maintaining an IV KEY: Nursing Process
Step: Planning MSC: NCLEX: Physiological Integrity:
pharmacological therapies
, 4. A patient who requires an immediate transfusion of blood has previously signed a consent
form to receive it. The nurse confirms that the consent was signed within the last _____
hours.
a. 8
b. 12
c. 24
d. 48 to 72
ANS: D
A consent to receive blood must be signed by the patient, usually no more than 48 to
72 hours before receiving the blood product.
DIF: Cognitive Level: Knowledge REF: m 727 OBJ: Clinical Practice #7
TOP: Blood Transfusion Consent Form KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
pharmacological therapies
5. A patient complains of chills, back pain, and shortness of breath a few minutes after the
blood infusion is started. The first thing the nurse should do is:
a. slow down the blood infusion.
b. stop the blood infusion and start the saline.
c. monitor vital signs and call the physician.
d. start low-flow oxygen as per facility protocol.
ANS: B
If a transfusion reaction occurs, such as chills, back pain, and shortness of breath or
itching, the nurse should stop the infusion and start the saline to keep the line open.
DIF: Cognitive Level: Application REF: m 729, Skill 36-6 OBJ:
Theory #6 TOP: Blood Transfusion Reaction KEY: Nursing Process
Step: Implementation MSC: NCLEX: Safe Effective Care
Environment: safety and infection control
6. The LVN/LPN is told by the RN to discontinue an IV line to the patient. The best nursing
action is to:
a. check the physicians order.
b. stop the IV flow by clamping the tubing securely.
c. wash hands and don gloves.
d. quickly withdraw the cannula and apply pressure.
ANS: A
Checking the physicians order will prevent inadvertently discontinuing the IV and
having to restart it.
DIF: Cognitive Level: Application REF: m 727, Steps 36-4 OBJ:
Clinical Practice #6 TOP: Discontinuing an IV KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
basic care and comfort
7. The nurse caring for a patient with an intermittent IV device should:
a. attach continuous fluid infusion to the device.
b. infuse saline or heparin solution to maintain patency.
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. A patient is to have an IV insertion site changed. The current line is in the lower right
forearm. Which location is contraindicated for the new site?
a. Right upper forearm
b. Right hand
c. Left upper forearm
d. Left hand
ANS: B
A new IV site should not be placed distal to an old site; the right hand is distal to the
right forearm, so it should not be used.
DIF: Cognitive Level: Analysis REF: m 710 OBJ: Clinical Practice #4
TOP: Changing IV Site KEY: Nursing Process Step:
Planning MSC: NCLEX: Physiological Integrity: reduction of risk
potential
2. The nurse would plan to get another nurse to try to obtain a successful venipuncture if the
first nurse was not successful in _____ attempt(s).
a. five
b. three
c. two
d. one
ANS: C
If the nurse cannot initiate a patent IV in two attempts, it is good judgment to ask
another nurse to perform the task.
DIF: Cognitive Level: Application REF: m 715, Skill 36-1 OBJ:
Clinical Practice #4 TOP: Starting an IV KEY: Nursing Process
Step: Planning MSC: NCLEX: Physiological Integrity: basic
care and comfort
3. A nurse is aware that for a patient with a continuous IV infusion running, the IV bag
should be changed when only ______ mL of solution remains in the bag.
a. 10
b. 25
c. 50
d. 100
ANS: C
When the container has only 50 mL of solution left, the next ordered solution is added
to the setup and the flow begun to prevent air from entering the line.
DIF: Cognitive Level: Comprehension REF: m 716 OBJ: Clinical
Practice #5 TOP: Maintaining an IV KEY: Nursing Process
Step: Planning MSC: NCLEX: Physiological Integrity:
pharmacological therapies
, 4. A patient who requires an immediate transfusion of blood has previously signed a consent
form to receive it. The nurse confirms that the consent was signed within the last _____
hours.
a. 8
b. 12
c. 24
d. 48 to 72
ANS: D
A consent to receive blood must be signed by the patient, usually no more than 48 to
72 hours before receiving the blood product.
DIF: Cognitive Level: Knowledge REF: m 727 OBJ: Clinical Practice #7
TOP: Blood Transfusion Consent Form KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
pharmacological therapies
5. A patient complains of chills, back pain, and shortness of breath a few minutes after the
blood infusion is started. The first thing the nurse should do is:
a. slow down the blood infusion.
b. stop the blood infusion and start the saline.
c. monitor vital signs and call the physician.
d. start low-flow oxygen as per facility protocol.
ANS: B
If a transfusion reaction occurs, such as chills, back pain, and shortness of breath or
itching, the nurse should stop the infusion and start the saline to keep the line open.
DIF: Cognitive Level: Application REF: m 729, Skill 36-6 OBJ:
Theory #6 TOP: Blood Transfusion Reaction KEY: Nursing Process
Step: Implementation MSC: NCLEX: Safe Effective Care
Environment: safety and infection control
6. The LVN/LPN is told by the RN to discontinue an IV line to the patient. The best nursing
action is to:
a. check the physicians order.
b. stop the IV flow by clamping the tubing securely.
c. wash hands and don gloves.
d. quickly withdraw the cannula and apply pressure.
ANS: A
Checking the physicians order will prevent inadvertently discontinuing the IV and
having to restart it.
DIF: Cognitive Level: Application REF: m 727, Steps 36-4 OBJ:
Clinical Practice #6 TOP: Discontinuing an IV KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
basic care and comfort
7. The nurse caring for a patient with an intermittent IV device should:
a. attach continuous fluid infusion to the device.
b. infuse saline or heparin solution to maintain patency.
