CHAPTER 18 INTRAVENOUS THERAPY
EXAM QUESTIONS WITH COMPLETE
SOLUTIONS
A patient with a subclavian line complains of shortness of breath after an infusion.
The patient is diaphoretic, and the blood pressure is 168/100 mm Hg, higher than a
previous reading of 140/86 mm Hg. What should the nurse assess these symptoms
as indicating?
a. Fluid overload from too rapid an infusion
b. Incorrect dilution of the infused drug
c. Infection from faulty aseptic technique
d. Embolus from introduced air or blood clot - ANSWER-ANS: D
Air can be introduced into the subclavian line from any of the ports that are left
unclamped. The symptoms have occurred too quickly for an overload or infection.
A patient has had an air embolus. What should be the immediate action of the quick-
thinking nurse?
a. Turns the patient to the left side and lowers the head of the bed
b. Calls the "code team"
c. Gives oxygen at 100% in a nonrebreathing mask
d. Notifies the charge nurse - ANSWER-ANS: A
Lowering the head of the bed and turning the patient to the left side traps the air in
the left atrium, where it can be more readily reabsorbed.
An older adult patient is quite ill and confused and begins to cry pitifully when a
nurse approaches the bed to start an intravenous (IV) line. What is the best action
for the nurse at this time?
a. Keep the infusion equipment out of sight as much as possible, talk slowly, and
divert the attention of the patient.
b. Inform the patient that the physician has ordered the IV and calmly continue to
prepare the site and start the IV.
c. Give an analgesic as ordered, wait a few minutes, and then proceed.
d. Restrain the patient's arm to a padded armboard and proceed as directed. -
ANSWER-ANS: A
Confusion during a bout of illness in older adults is common. Distraction and
reassurance usually gain compliance. Medication and restraints are not indicated.
What action should the nurse implement when discontinuing an intravenous (IV)
line?
a. Remove the dressing, remove the catheter, dispose of the used equipment in the
sharps container, and chart observations and actions.
b. Observe the site for redness, swelling, and pain, and put on sterile gloves.
Remove the dressing catheter and chart the findings and action.
c. Observe the site for redness, swelling, and pain, and put on clean gloves. Remove
the dressing and catheter, place a 2 2 dressing over the site, and chart the findings
and action.
, d. Observe the site for redness, swelling, and pain and put on clean gloves. Remove
the dressing and catheter; chart the findings and action. - ANSWER-ANS: C
This procedure is not sterile. Clean gloves protect the nurse from the body fluids.
Placement of a small 2 2 dressing keeps the area clean until the insertion site
closes.
Using an IV infusion system that delivers 60 drops/mL, a nurse hangs a 500-mL bag
of normal saline (NS) at 0800. The physician has ordered a rate of 20 mL/hr. What
should the nurse set the roller clamp to deliver?
a. 10 gtt/min
b. 20 gtt/min
c. 25 gtt/min
d. 30 gtt/min - ANSWER-ANS: B
20 mL (amount to be infused in 1 hr) 60 gtt = 1200 gtt/hr. 1200 gtt 60 min in 1 hr = 20
gtt/min. This roller clamp is an old method to determine rates, but in the case of a
nonavailability of electronic delivery devices, it is a good thing to know.
A physician prescribes a hypertonic intravenous line for an extremely edematous
patient. What solution should the nurse anticipate to be prescribed?
a. D5W in NS
b. Lactated Ringer solution
c. D5W in 0.25 NS
d. 10% glucose in water - ANSWER-ANS: D
D5W in 0.25 NS is hypotonic. D5W in NA and lactated Ringer solution is isotonic;
10% glucose is hypertonic.
What is the source of calories in IV solutions?
a. Electrolytes
b. Dextrose
c. Vitamins
d. Water - ANSWER-ANS: B
Dextrose is sugar and the source of calories.
What signs of infiltration should be assessed by a nurse?
a. Burning sensation, pain, and puffy
b. Pain, heat, and puffy
c. Burning sensation and no feeling at the site
d. Red streak up the arm - ANSWER-ANS: A
Intravenous fluid in the immediate tissues causes pain and swelling of the adjacent
tissues.
A physician orders an infusion of 1000 mL of 5% dextrose in 0.45% NS to be
completed in 8 hours. The IV delivery system's drop factor is 20 gtt. How many mL/hr
should the nurse set the electronic infusion pump to deliver the infusion?
a. 125 mL/hr
b. 100 mL/hr
c. 85 mL/hr
d. 42 mL/hr - ANSWER-ANS: A
Whole volume (1000 mL) divided by number of hours (8) = 125 mL/hr. Volume per
hour (125 mL) 8 hr = 1000 mL.
EXAM QUESTIONS WITH COMPLETE
SOLUTIONS
A patient with a subclavian line complains of shortness of breath after an infusion.
The patient is diaphoretic, and the blood pressure is 168/100 mm Hg, higher than a
previous reading of 140/86 mm Hg. What should the nurse assess these symptoms
as indicating?
a. Fluid overload from too rapid an infusion
b. Incorrect dilution of the infused drug
c. Infection from faulty aseptic technique
d. Embolus from introduced air or blood clot - ANSWER-ANS: D
Air can be introduced into the subclavian line from any of the ports that are left
unclamped. The symptoms have occurred too quickly for an overload or infection.
A patient has had an air embolus. What should be the immediate action of the quick-
thinking nurse?
a. Turns the patient to the left side and lowers the head of the bed
b. Calls the "code team"
c. Gives oxygen at 100% in a nonrebreathing mask
d. Notifies the charge nurse - ANSWER-ANS: A
Lowering the head of the bed and turning the patient to the left side traps the air in
the left atrium, where it can be more readily reabsorbed.
An older adult patient is quite ill and confused and begins to cry pitifully when a
nurse approaches the bed to start an intravenous (IV) line. What is the best action
for the nurse at this time?
a. Keep the infusion equipment out of sight as much as possible, talk slowly, and
divert the attention of the patient.
b. Inform the patient that the physician has ordered the IV and calmly continue to
prepare the site and start the IV.
c. Give an analgesic as ordered, wait a few minutes, and then proceed.
d. Restrain the patient's arm to a padded armboard and proceed as directed. -
ANSWER-ANS: A
Confusion during a bout of illness in older adults is common. Distraction and
reassurance usually gain compliance. Medication and restraints are not indicated.
What action should the nurse implement when discontinuing an intravenous (IV)
line?
a. Remove the dressing, remove the catheter, dispose of the used equipment in the
sharps container, and chart observations and actions.
b. Observe the site for redness, swelling, and pain, and put on sterile gloves.
Remove the dressing catheter and chart the findings and action.
c. Observe the site for redness, swelling, and pain, and put on clean gloves. Remove
the dressing and catheter, place a 2 2 dressing over the site, and chart the findings
and action.
, d. Observe the site for redness, swelling, and pain and put on clean gloves. Remove
the dressing and catheter; chart the findings and action. - ANSWER-ANS: C
This procedure is not sterile. Clean gloves protect the nurse from the body fluids.
Placement of a small 2 2 dressing keeps the area clean until the insertion site
closes.
Using an IV infusion system that delivers 60 drops/mL, a nurse hangs a 500-mL bag
of normal saline (NS) at 0800. The physician has ordered a rate of 20 mL/hr. What
should the nurse set the roller clamp to deliver?
a. 10 gtt/min
b. 20 gtt/min
c. 25 gtt/min
d. 30 gtt/min - ANSWER-ANS: B
20 mL (amount to be infused in 1 hr) 60 gtt = 1200 gtt/hr. 1200 gtt 60 min in 1 hr = 20
gtt/min. This roller clamp is an old method to determine rates, but in the case of a
nonavailability of electronic delivery devices, it is a good thing to know.
A physician prescribes a hypertonic intravenous line for an extremely edematous
patient. What solution should the nurse anticipate to be prescribed?
a. D5W in NS
b. Lactated Ringer solution
c. D5W in 0.25 NS
d. 10% glucose in water - ANSWER-ANS: D
D5W in 0.25 NS is hypotonic. D5W in NA and lactated Ringer solution is isotonic;
10% glucose is hypertonic.
What is the source of calories in IV solutions?
a. Electrolytes
b. Dextrose
c. Vitamins
d. Water - ANSWER-ANS: B
Dextrose is sugar and the source of calories.
What signs of infiltration should be assessed by a nurse?
a. Burning sensation, pain, and puffy
b. Pain, heat, and puffy
c. Burning sensation and no feeling at the site
d. Red streak up the arm - ANSWER-ANS: A
Intravenous fluid in the immediate tissues causes pain and swelling of the adjacent
tissues.
A physician orders an infusion of 1000 mL of 5% dextrose in 0.45% NS to be
completed in 8 hours. The IV delivery system's drop factor is 20 gtt. How many mL/hr
should the nurse set the electronic infusion pump to deliver the infusion?
a. 125 mL/hr
b. 100 mL/hr
c. 85 mL/hr
d. 42 mL/hr - ANSWER-ANS: A
Whole volume (1000 mL) divided by number of hours (8) = 125 mL/hr. Volume per
hour (125 mL) 8 hr = 1000 mL.
